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National Safety Code

Safety Fitness Certificate Application Package

Alberta Transportation - Carrier Services

Room 401, 4920 - 51 Street Red Deer, AB T4N 6K8

National Safety Code and Operating Authority Administration

Phone #: 403-340-5444 (Toll free in Alberta by first dialing 310-0000) Fax #: 403-340-4806 Website: www.transportation.alberta.ca

Table of Contents

Subject Page

Definitions ................................................................................. 3 Frequently Asked Questions ............................................................ 4 Insurance Requirements .................................................................. 5 - 7 Safety Obligations ........................................................................ 8 - 9 Operating Status Information ............................................................ 9 Carrier Profile Information .............................................................. 10 Education Manual Information ......................................................... 11 Regulatory Requirements & Department Contact Information ..................... 12 Application Form for Safety Fitness Certificate ....................................... 13 - 18 Payment Form ............................................................................. 18

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DEFINITIONS

Applicant

a person who files a complete application and is the registered owner of the vehicle.

Carrier

an owner of a commercial vehicle in respect of which a Safety Fitness Certificate (SFC) is issued, who holds a Safety Fitness Certificate or is required to hold a Safety Fitness Certificate.

Commercial Vehicle

a vehicle operated on a highway by or on behalf of a person for the purpose of providing transportation but does not include private passenger vehicles. This includes the transportation of owners own goods and permanently mounted equipment.

Commercial Vehicle Inspection Program (CVIP)

a mandatory and legislated mechanical inspection of a commercial vehicle. (Note: This does not constitute a maintenance program.)

National Safety Code (NSC)

a set of 16 standards used by all Canadian jurisdictions to enhance the safety of truck and bus carriers. Under the NSC Program, carriers must obtain a Safety Fitness Certificate (SFC) and maintain an acceptable safety fitness rating.

National Safety Code (NSC) Vehicle

one or more commercial vehicles registered in the name that the certificate applies to.

Operating Authority Certificate

a certificate issued by the Registrar authorizing the operation of a commercial vehicle to transport passengers.

Safety Fitness Certificate (SFC)

a certificate issued by the Registrar once a completed Safety Fitness Certificate Application is received, authorizing the carrier to operate commercial trucks and bus/van. This is not your annual/semi-annual mechanical inspection.

Private Passenger Vehicle

a vehicle used solely for personal transportation: a. including the carriage of goods intended for the use or enjoyment of the owner of the vehicle or members of the owner's household, but b. not including, in respect of a person's business, work or employment, the carriage of passengers or of goods, except for sample cases or display goods that are conveyed by a salesperson and that are not for delivery or resale.

Prorate

the process of calculating registration fees and taxes for multiple jurisdictions. Prorated registrations are applicable to commercial carriers who are based in Alberta. To be considered for prorate registration; vehicles must travel interprovincially and/or inter-nationally in Alberta and at least one other province/territory/state.

Registered Owner

the person or company who's name appears on the vehicle certificate of registration. .

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Frequently Asked Question's

Frequently Asked Questions:

1. What is involved in changing my operating status? To change your operating status (Provincial or Federal) an Operating Status Application Form must be completed. Refer to information on Page 9. 2. Is the Safety Fitness Certificate transferable? Certificates are issued only to the registered owner of a commercial vehicle. If there is a change to the registered owner's name a new certificate is required and you must re-apply. 3. Do I require a Commercial Vehicle Inspection (Mechanical Inspection) from a Certified Inspection Facility? A commercial vehicle inspection is required every 12 months for a truck/tractor or trailer or any combination of these vehicles, with a registered weight of 11,794 kilograms or more operating solely within Alberta. A commercial vehicle inspection is required every 6 months for a vehicle designed for carrying 11 or more persons including the person driving the vehicle. 4. Can I fax my application? The application can be faxed if a credit card number is provided on the form. If faxed, the original is not required to be sent. 5. Do farmers have to obtain a Safety Fitness Certificate? Farmers are exempt from obtaining a Safety Fitness Certificate if traveling solely within Alberta. However, if you register a farm-plated vehicle with a registered weight of more than 4,500 kilograms and you leave the province for farming business you are required to obtain a Safety Fitness Certificate. 6. Do I require a Safety Fitness Certificate, when: a. I only own or operate permanently mounted equipment? b. I do not haul for hire, hauling only my own goods? c. I do not haul any "goods" on a trailer; it is just a small truck (i.e. welding truck)? A Safety Fitness Certificate is required: to operate all commercial vehicles based on the registered weight. If your vehicle has a registered weight of 11,794 kilograms or more and you operate solely within Alberta; OR if you leave the province and your registered weight is more than 4,500 kilograms. 7. If I register another truck or commercial passenger vehicle; do I have to apply for another Safety Fitness Certificate? No, a Safety Fitness Certificate applies to all commercial vehicles under the NSC Program that are registered to the name that appears on the certificate. 8. My truck weighs 11,790 kilograms but I pull a trailer with a weight of 6,600 kilograms. Do I need to comply? Yes as it is the truck/tractor or trailer or any combination of these vehicles.

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INSURANCE REQUIREMENTS

AR 314/2002 SECTION 25 - LIABILITY INSURANCE

The registered owner of a commercial vehicle used or intended to be used to transport goods on a highway for which a certificate of registration under the Traffic Safety Act is issued, must maintain, for each vehicle, in respect of any one accident, insurance against liability resulting from bodily injury to or the death of one or more persons and loss of or damage to property of others, other than goods, of at least: $2,000,000 for transportation of dangerous goods set out in Schedule 1 of the Dangerous Goods Transportation and Handling Regulation under the Dangerous Goods and Transportation Handling Act in the quantities indicted in Column 7 of that Schedule, in respect of which an emergency response plan is required to be filed under Part 7 of those Regulations; and $1,000,000 in all other cases.

Carriers operating outside of Alberta should contact other jurisdictions to ensure all insurance requirements are met.

AR 314/2002 SECTION 24 ­ CARGO INSURANCE

24(2) A registered owner must maintain cargo insurance against loss of or damage to goods transported. (a) for each commercial vehicle engaged in the transportation of farm produce other than dairy products, at least $600; (b) for each commercial vehicle engaged only in the transportation of unprocessed milk or cream, an amount equal to the actual cash value of the goods. (3) If a person is engaged in the transportation of a mobile home, that person must maintain, in respect of the mobile home, insurance acceptable to the Registrar that, (a) for a single wide mobile home (i) provides coverage against loss or damage for the greater of (A) $10 000, or (B) the cash value of the mobile home and its contents, if any and (ii) provides for collision coverage on the mobile home (b) for a double wide mobile home, (i) provides coverage against loss or damage for the cash value of the 2 halves and their contents, if any, (ii) provides that if one of the halves is damaged to the extent that it is not practicable to repair it, the other half will be considered to have been also destroyed, and (iii) provides for collision coverage on the mobile home. (4) If subsections (2) and (3) do not apply, the registered owner who transports goods on a commercial vehicle must maintain cargo insurance against loss or damage to goods transported as follows: see information on page 6.

(5) In this section, "registered gross weight" means the weight specified on the certificate of registration issued in respect of the vehicle.

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Vehicle Specifications For each vehicle having a registered gross weight not exceeding 12,700 kilograms For each vehicle having a registered gross weight exceeding 12,700 kilograms but not exceeding 18,000 kilograms For each vehicle having a registered gross weight of at least 18,000 kilograms but not exceeding 21,000 kilograms For each vehicle having a registered gross weight exceeding 21,000 kilograms but not exceeding 37,000 kilograms For each vehicle having a registered gross weight exceeding 37,000 kilograms

Minimum Cargo Insurance Required $15,000 $20,000 $20,000 $27,000 $32,000

SCHEDULE 1 Goods Exempt From Cargo Insurance alfalfa (raw or pelletised) animal feed and related concentrates and supplements (not for human consumption) asphalt mix (bituminous) brick cement (dry or wet) clay coal concrete products condensate crude oil crushed glass dead animals drilling mud fodder garbage grain granite granulite gravel herculite lime loam logs lumber newspapers organic manure peat moss propane salt sand sawdust scrap iron septic tank refuse snow stone sugar beets (raw or pelletised) sulphur topsoil water woodchips

Note: Section 24(1)(b) indicates that cargo does not apply to a person who owns the goods that the person is transporting.

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AR 314/2002 SECTION 26 - PUBLIC PASSENGER HAZARD INSURANCE:

26(1) The registered owner of (a) (b) a commercial vehicle for which an operating authority certificate is required or issued, or a commercial vehicle operated as an airport transportation service, with or without compensation paid by passengers, by which passengers are transported, (i) from one or more pick-up points to an airport and the only drop off point is the airport, or (ii) from an airport to one or more drop off points and the only pick-up point is the airport; a rented commercial vehicle that is used or intended to be used to transport passengers for compensation,

(c)

must not operate the vehicle unless the vehicle is covered by a policy of automobile insurance providing passenger hazard coverage in at least the following amounts: (d) (e) (f) $400 000 for bodily injury or death of any one person as a result of any single accident; if the manufacturer's seating capacity of the vehicle was originally designed for 10 passengers or fewer, including the driver, $1 000 000 for bodily injury or death of 2 or more persons as a result of any single accident; if the manufacturer's seating capacity of the vehicle was originally designed for carrying 11 passengers or more, including the driver, $2 000 000 for bodily injury or death of 2 or more persons as a result of any single accident.

(2) When requested to do so by the Registrar, the holder of an operating authority certificate issued in respect of a commercial vehicle must direct the insurer to file with the Registrar, as the case may be, evidence of the current policy referred to in subsection (1). (3) Nothing in this section effects the obligations of the person under the Insurance Act.

AR 314/2002 SECTION 26.1(1) - SCHOOL BUS PASSENGER HAZARD INSURANCE:

26.1(1) Every school bus that is used for a purpose under section 19 of the Commercial Vehicle Safety Regulation must be covered by a policy of automobile insurance providing passenger hazard coverage in at least the following amounts: (a) $200 000 for bodily injury or death of any one person as a result of any single accident; (b) if the manufacturer's seating capacity of the vehicle was originally designed for 15 passengers or fewer, including the driver, $500 000 for bodily injury or death of 2 or more persons as a result of any single accident; (c) if the manufacturer's seating capacity of the vehicle was originally designed for 16 passengers or more, including the driver, $1 000 000 for bodily injury or death of 2 or more persons as a result of any single accident. (2) When requested to do so by the Registrar, the owner of the school bus must direct the insurer to file with the Registrar, as the case may be, evidence of the current policy referred to in subsection (1). (3) Nothing in this section affects the obligations of a person under the Insurance Act.

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SAFETY OBLIGATIONS

The following information is designed to assist carriers in understanding and meeting their legal requirements. This is a summary only. For more information one must refer to the regulations. The carrier is obligated to have comprehensive knowledge of and be able to demonstrate compliance with "safety laws" that apply to their operations. "Safety laws" are the laws governing the: Operation of commercial trucks and passenger vehicles on highways; Equipment and motor vehicle standards as they apply to commercial trucks and passenger vehicles; Allowed weight of commercial vehicles and buses; Transportation of dangerous goods; Loading, securing and carrying of loads. Driver hours of service.

In addition, the carrier must comply with the following: 1. Set out in writing, and fully implement, a safety program. This program will form the basis for demonstrating safety and compliance and would include at least: (a) (b) (c) Identification of company policies and procedures to ensure staff comply with safety laws; Designation of a "Safety Officer" to coordinate safety and compliance activities; Clear written documentation, relating to the safe operation of vehicles including: Such subjects as speed limits, drugs and alcohol, defensive driving, load security, fuelling, etc; Provisions for proper record completion of such documents as Bills of Lading, Manifests, Dangerous Goods documents, time records and drivers' daily logs, weigh slips, etc; Provisions stating that employees are to "comply with the law"; Instructions for the use of safety equipment that pertains to their operation, including the use of flags and flares, fire extinguisher, goggles, hard hats, etc; Provisions for a staff disciplinary policy; Provisions for providing training to employees and an ongoing program for evaluating their skills; Retention of complete records for each driver in accordance with Section 41(1) of the Commercial Vehicle Certificate and Insurance Regulation AR 314/2002; Provisions for ensuring that all drivers are properly qualified for the type of vehicle(s) they operate.

(d) (e) (f) 2. 3. 4.

Maintain at least the minimum Public Liability and Cargo Insurance (if required), or Passenger Hazard Insurance unless otherwise exempted by regulation. Accept responsibility for all violations, inspections and collisions for all vehicles registered (or subject to a short term lease) in the carrier's name and for drivers operating those vehicles. Set out in writing, and fully implement, a continuous and regular program for the inspection, maintenance and repair of the carrier's commercial vehicles. This would include the retention of a complete vehicle maintenance record for each vehicle being operated, including trucks, tractors, trailers, jeeps, boosters, etc. For more information, see the Commercial Vehicle Safety Regulation, AR 121/2009.

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5.

Ensure that all vehicles are in compliance with the Commercial Vehicle Inspection Program (CVIP) requiring annual inspections for trucks/tractors and trailers and semi-annual inspection(s) for buses. Maintain all records identified above at the carrier's principal place of business in Alberta as declared within this application. If you wish to retain records at another location, a divided record permit must first be obtained from Alberta Transportation. For more information or a copy of the permit application form, contact the department at 403-755-6111 (toll free in Alberta by first dialing 310-0000).

6.

OPERATING STATUS INFORMATION:

On January 1, 2006 Transport Canada amended the Motor Vehicle Transport Act to require a new Motor Carrier Safety Fitness Certificate for federal regulated carriers. As of January 1, 2006, the Safety Fitness Certificate identifies one of two types of Operating Status. A "Provincial" Operating Status authorizes the operation of commercial vehicles ONLY within Alberta and applies to commercial trucks registered for 11,794 kilograms or more, or a commercial vehicle designed for carrying 11 or more persons including the person driving the vehicle. A "Federal" Operating Status authorizes the operation of commercial or farm-plated vehicles throughout Canada registered for a weight of more than 4,500 kilograms, or a vehicle designed for carrying 11 or more persons including the person driving the vehicle, if operated for other than personal use. A carrier with a Federal Operating Status whose business has changed to the extent that they intend to cease conducting business outside of Alberta may request that their Operating Status be changed to Provincial. This option is only for those carriers implementing long term changes to their business and may not be used to address short term operational needs. Alberta is enforcing Federal requirements on carriers who operate a commercial vehicle outside of Alberta. Once it is determined that Federal legislation applies to a carrier, it will apply to their entire NSC fleet, even those operating point-to-point within Alberta. Carriers found to be operating outside of Alberta with a Provincial Operating Status are subject to prosecution and/or having their vehicle detained at roadside, until their Operating Status is changed to Federal by Alberta Transportation. The application for Change of Operating Status can be found at: www.transportation.alberta.ca/Content/docType276/Production/Operating_Status_Applic_Form.pdf Note: Carriers operating vehicles outside of the Province of Alberta for personal use only should contact the other jurisdictions to determine compliance requirements. A carrier's request for a change in Operating Status will only be considered if the carrier completes and submits; A Change of Operating Status Application Form (pdf 33K), and A $50.00 application fee payable by Visa/MasterCard or by cheque payable to the "Minister of Finance".

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CARRIER PROFILE INFORMATION

Alberta Transportation has now made Carrier Profiles available through the internet website. Profiles may be obtained by an authorized representative of the corporation. For the purposes of monitoring the activities and safety record of carriers, the Registrar must establish and maintain a carrier profile for persons who operate a commercial vehicle. A carrier profile contains on-road performance information that is assigned to the registered owner or driver employed or engaged by the registered owner such as records of any collision, conviction of safety laws, traffic violations, commercial vehicle inspections conducted by a peace officer or by a government authority in another Province /Territory/State. It also includes any other information the Registrar considers appropriate in order to maintain a record of compliance with safety laws. To obtain a carrier profile the direct link is: https://www.trans.gov.ab.ca/TravisWebLogin/redirect.htm If you are a new user, once you have located the Online Services page, select "Need a User ID? Register" and follow the instructions provided to register. Once you have completed your registration, your request will be reviewed and a temporary password will be provided to you through your e-mail address. This will then allow you to log back on with the password and obtain your profile. You are allotted two free profiles per calendar year. Ensure that you check the "request free" box for the profile if you wish to have it at no charge. Provided you have selected "request free", there will be no charge to your VISA/Mastercard that you have entered to obtain two profiles at no charge. Once you have obtained your two free profiles, there is a fee of $2.00 + GST per page. You also have the capability of selecting the time period you wish to cover on your profile as opposed to the preset time period of one year. If carriers are interested in requesting Part 6 ­ Monitoring summary, the time of your submission is important. To obtain up to date information, submit your profile request after the first Sunday of the month. This is due to internal system processing of data. Should you have any questions regarding obtaining your Carrier Profile, please contact 403-340-5430. Call toll free by dialing 310-0000 then the ten digit number. NOTE: If you are a hotmail account user you must use MSN Live Hotmail in order for the profile to be opened. Old MSN Hotmail accounts are not allowing the attachment to be opened.

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NOTICE

Education Manual

Carrier Services, a section of Alberta Infrastructure and Transportation (INFTRA), is responsible for commercial truck and bus carriers under Alberta's National Safety Code (NSC) Program. To assist these companies and individuals, Carrier Services has prepared a comprehensive "education manual" titled "Commercial Vehicle Safety Compliance In Alberta" to help registered owners of commercial vehicles (whether an individual or a company) and their drivers to better understand their transportation compliance requirements. This manual covers many of the critical business and regulatory areas to assist all commercial carriers and drivers. It is in a modular format so you can view/print all of it or only the portions you need. A copy of this document is available from the department's web site at: www.transportation.alberta.ca/671.htm Some of the topics included in this document include: o o o o o o o o o The National Safety Code Safety Programs, Record Keeping and Driver Files Preventive Maintenance, Record Keeping and Vehicle Files Hours of Service Dangerous Goods Carrier Profiles and Safety Ratings Carrier Monitoring and Intervention Passenger Transportation Services Cargo Securement

If you want to purchase a copy of this document instead of printing it on-line, contact one of the following organizations: Alberta Forest Products Association (AFPA) (members only) Alberta Motor Transport Association (AMTA) (members and non-members) Petroleum Services Association of Canada (PSAC) (members only) Canadian Association of Oilwell Drilling Contractors (members only) More Information: Information on the Alberta legislation and on the NSC standards is available on the internet: www.qp.gov.ab.ca www.ccmta.ca www.transportation.alberta.ca (for the Alberta legislation) (for the NSC standards, including Standard #10 & #13) (for compliance and general transportation information) 780-452-2841 800-267-1003 403-264-4195 403-264-4311

Contact:

Carrier Services #401, 4920 ­ 51 Street Red Deer, AB T4N 6K8 Phone: Fax: 403-755-6111 (toll-free in Alberta by first dialing 310-0000) 403-340-4811

Email:

[email protected]

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SAFETY FITNESS CERTIFICATE

Unless indicated otherwise, all information requested on this application is mandatory and must be completed. The Alberta Traffic Safety Act and Transport Canada's Motor Vehicle Transport Act (1987) requires all persons registering the following commercial vehicle(s) to comply with the requirement to obtain a Safety Fitness Certificate: a truck/tractor or trailer or any combination of these vehicles that has a registered weight of 11,794 kilograms or more, travelling solely within Alberta, a truck/tractor or trailer or any combination of these vehicles that weighs or is registered with a weight of more than 4,500 kilograms that is used or intended to be used to transport goods on a highway outside of Alberta, including a farm-plated vehicle; or, a "bus" (including vans) that is a commercial vehicle designed for carrying 11 or more persons, including the person driving the vehicle, and that is used or intended to be used for the transportation of persons.

Some exemptions to this requirement do apply. For example, persons operating a farm-plated vehicle solely for conducting their own farm operation are exempt from the requirements of obtaining a Safety Fitness Certificate provided they travel solely within Alberta. New applicants with a commercial truck registered with a weight of 11,794 kilograms or more must obtain a 60 day Temporary Safety Fitness Certificate from an Alberta Registry Agent at time of first registration. You are required by law to carry the original or a copy of your Safety Fitness Certificate in your vehicle at all times. A Safety Fitness Certificate may be suspended or cancelled at any time. Persons/Corporations/Societies operating a "bus/van" may be required to have an Operating Authority as well as a Safety Fitness Certificate. For more information on Operating Authority requirements, contact 403340-5444.

Department Contact Information

Carrier Services: For information regarding Safety Fitness Certificate applications, carrier profiles and Operating Authorities: Phone: 403-340-5444 Fax: 403-340-4806 For information on regulatory requirements, audits, departments progressive discipline, safety permits and transportation consultants: Phone: 403-755-6111 Fax: 403-340-4811 Dangerous Goods and Rail Safety: For information on shipping dangerous goods, investigating incidents and complaints, and providing technical information on hazardous chemicals: Phone: 780-422-9600 or 800-272-9600 Fax: 780- 427-1044 Vehicle Safety: For information regarding annual/semi-annual Commercial Vehicle Inspection Program, vehicle maintenance standards, inspection facility certificate, inspection technician certificates and cargo securement. Phone: 780-427-8901 Fax: 780-422-3682

Prorate: For information about prorating Alberta registered commercial vehicles for travel to other jurisdictions and using the International Registration Plan (IRP): Phone: 403-297-2920 Fax: 403-297-2917

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Application PackageSafety Fitness Certificate

SECTION 1 - APPLICANT INFORMATION (Please Print)

Complete ONLY ONE of the following 1A, 1B, or 1C with the name(s) that appear on the vehicle registration:

1A Corporate/Organization/ Society Name as registered with Alberta Corporate Registry

Legal Name (Trade Name not acceptable)

1B Individual Name

(Last)

(First)

(Middle)

Driver's License # and Province/Territory/State:

1C Joint Names

Note: Where more than one name may appear on your vehicle registration as individual/individual name, individual/company name, or company/company name.

1D Mailing Address

Street/Box #: City: Phone #: ( Email: ) Province: Cell Phone #: ( ) Postal Code: Fax #: ( )

Principle Place of Business in Alberta (Must be a street address or legal land location, not a box

1E number) This is where all records required by safety laws are retained, including driver/vehicle files and safety/maintenance program documents. (If different then what appears in 1D)

Street/Legal Land Location City: Phone #: ( ) Province: Alberta Cell Phone #: ( ) Postal Code: Fax #: ( )

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SECTION 2 - INSURANCE INFORMATION (SEE INSURANCE REQUIREMENTS PAGE 5 ­ 7) 2A Commodity Information

1. Are commodities (goods hauled) "owners own goods"?

Yes No

2. If you haul Dangerous Goods as set out under the Schedule 1 of the Dangerous Goods Regulation, please list the Product Identification Number(s) (e.g. UN 1267)

2B TRUCKS ONLY ­ Public Liability and Property Damage Insurance (PL/PD)

Name of Insuring Company (agent/broker is not acceptable): Policy/Binder Number: Amount of Coverage: $

2C TRUCKS ONLY ­ Cargo Insurance

If you haul commodities (goods) identified in Schedule 1 (see pages 5 and 6) or owners own goods, which are exempt from cargo insurance coverage proceed to Section 3. If commodities (goods) hauled require cargo insurance, provide information below: Name of Insuring Company (agent/broker is not acceptable): Policy/Binder Number: Amount of Coverage: $

BUSES (INCLUDING VANS) ONLY ­ 2D Passenger Hazard/Short-Term Rental Insurance Policy Endorsement:

Vehicles that are designed for carrying 11 or more persons including the person driving the vehicle.

Indicate which endorsement is provided/maintained from your insurance company (see page 7):

SEF 6C ­ Public Passenger Vehicle Endorsement SEF 6B ­ School Bus Endorsement

Policy/Binder Number: Amount of Coverage specified under the endorsement: SEF 101 ­ Public Passenger Vehicle Endorsement

SEF 5C ­ Short Term Rental Endorsement PPVE ­ Public Passenger Vehicle Endorsement

$

Name of Insuring Company (agent/broker is not acceptable):

If you maintain an Umbrella Policy with an SEF 101 Endorsement attached, provide information below: Name of Insuring Company (agent/broker is not acceptable): Policy/Binder Number: Amount of Coverage specified under the endorsement: $

NOTE:

When submitting an application for passenger vehicles attach a photocopy of your commercial vehicle inspection certificates completed within the last 6 months for all vehicles designed for carrying 11 or more persons including the person driving the vehicle.

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SECTION 3 - OPERATIONAL INFORMATION 3A Indicate if applicant operates under a trade name (operating as/doing business as):

Trade Name:

Do you travel outside Alberta with any of your Alberta base-plated commercial or 3B farm vehicles registered for more than 4,500 kilograms; AND/OR vehicles that are designed for carrying 11 or more persons (including the person driving the vehicle)? If "yes", list Province/Territory/State: Does the applicant have a current Safety Fitness Rating in another 3C Province/Territory/State? If "yes", list all Province/Territory/State and Safety Fitness Certificate numbers:

Province/Territory/State Province/Territory/State Certificate Number Certificate Number

Yes No Yes No

Certificate Rating Certificate Rating

Has the applicant, at any time within the past 5 years, been associated with a commercial operation that has been issued an "Unsatisfactory" or "Conditional" safety 3D fitness rating in any jurisdiction in North America? ("Associated" includes whether as an owner, director or manager.) If "yes", list all Province/Territory/State and Safety Fitness Certificate numbers:

Province/Territory/State Province/Territory/State Certificate Number Certificate Number

Yes No

Certificate Rating Certificate Rating

Does the applicant have multiple offices in Alberta where records are being kept for

3E National Safety Code vehicles? (driver/vehicle and safety/maintenance file records,

daily logs, or supporting documents)

Yes No

SECTION 4 - SAFETY AND MAINTENANCE INFORMATION 4A Compliance Information

1. Do you have and implement a written safety program that meets all requirements specified on pages 8 and 9? 2. Do you have and implement a written maintenance program that meets all requirements specified on pages 8 and 9? 3. Do you hire/have drivers other than yourself? 4. Do you own/operate a maintenance facility that is certified by Alberta Transportation to conduct annual and/or semi-annual inspections under the Commercial Vehicle Inspection Program (CVIP)?

If "yes", identify the Certified Facility Number(s):

Yes No In Progress Yes No In Progress Yes No Yes No Yes No

5. Have you accessed and read the Education Manual referred to on page 11?

4B commercial trucks and/or buses that are registered in the name of the applicant.

Safety:

(Last) (First) (Middle)

Name of designated person who is responsible for promoting the safe operation and maintenance of

(Phone #)

Maintenance:

(Last) (First) (Middle) (Phone #)

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SECTION 5 - INDUSTRY AND COMMODITY (GOODS) INFORMATION 5A

INDUSTRY TYPES Check one or more of the following that are applicable to your company. (Read Carefully) Agriculture (farm, ranch, tree planting, sod production, Provincial and Federal Governments

etc.)

Construction (roads, buildings, bridges, etc.) Forestry (logs, chips, rough and finished lumber,

pulp/paper)

Transportation (goods or passengers) Utilities (electricity, phone, natural gas) Wholesale and Retail (including general freight) Other:

Manufacturing and processing (finished products) Municipal Governments (counties, towns, education,

health)

Petroleum and Mining (upstream and downstream

operations)

5B

COMMODITY TYPES Check one or more of the following that are applicable to your company. (Read Carefully) Animals (live, all types) Fixed Equipment Artisans/Tradesmen Goods (welders, plumbers,

electricians, etc.) (cranes, service rigs, pumpers, etc.) Garbage / Refuse/Waste (non-dangerous goods)

Buildings and Modular Homes Bulk ­ Dry (non-dangerous goods, more than 450 litre

size)

Gravel/Rock/Dirt/Aggregates/Asphalt Household Goods (furniture moving, etc.) Log or Chip Hauling (excluding lumber) Other Farm Products (grain, hay, sod, etc.) Other Truck Load Products

(van trailers and flat deck trailers if commodity not specifically identified elsewhere in this list) Passengers (travelling to/from school only)

Bulk ­ Liquids (non-dangerous goods) Construction Materials (cement, lumber, shingles,

etc.)

Dangerous Goods ­ Bulk

(wet/dry in more than 450 litre containers)

Dangerous Goods ­ Non-Bulk (wet/dry in small

containers)

Emergency Equipment (ambulance, fire vehicle) Equipment

(dozers, automobiles, crushed cars, farm implements, etc.)

Passengers

(travelling to/from locations other than schools)

Retail Products

(groceries, mixed household and commercial goods, often carried in cube vans, courier vans or for pick up)

Other: * Forward only the Safety Fitness Application (pages 13 - 18) to Alberta Transportation for processing and retain the information pages of this package for your records.

NOTE: The registered owner should retain a copy of this completed application for your records.

You are required to produce a copy of your Safety Fitness Certificate at Alberta Registries when renewing commercial vehicle registrations or obtaining additional registrations.

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SECTION 6 ­ DECLARATION

A Safety Fitness Rating will be made "Inactive" and the certificate cancelled when a carrier has not maintained a commercial registration for more than 12 consecutive months on a vehicle which falls within the National Safety Code Program. If this occurs, carriers will have to reapply for a new Safety Fitness Certificate before they can again operate such vehicles. Providing false or misleading information may result in a suspension or cancellation of the Safety Fitness Certificate and/or vehicle registration and you may be charged with an offence or assessed an Administrative Penalty(s). I/We certify that the information contained in this application is, to the best of my/our knowledge, true, accurate and complete. I/We acknowledge and accept the responsibilities imposed by law, in relation to commercial motor vehicle(s) operated under the authority of a Safety Fitness Certificate.

This declaration must be signed by all individuals named on the vehicle registration (e.g. John Smith or John Smith & Mary Smith) (joint) and/or must be signed by an owner, manager or director when vehicle registration shows a corporate, society or organization name.

This application will be returned where the applicant has failed to fully complete all the questions and provide all requested information.

PRINT Name

Position

PRINT Name

Position

Signature

Date

Signature

Date

PRINT Name

Position

PRINT Name

Position

Signature

Date

Signature

Date

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Payment Form

APPLICATIONS ARE CONSIDERED INCOMPLETE WHEN RECEIVED WITHOUT THE FILING FEE PAYMENT.

Payment Options

FILING FEE OF $50.00 (GST NOT REQUIRED)

(PAYMENT IS NON-REFUNDABLE)

APPLICANT'S NAME (as shown on vehicle registration)

Telephone # (

)

Cell # (

)

CHEQUE OR MONEY ORDER *** Payable to "Government of Alberta" ***

Cheque Attached

Money Order Attached

CREDIT CARD INFORMATION

MasterCard Visa

Credit Card No

Expiry Date (mm/yy)

/

Name of Card Holder (Please Print)

Signature of Card Holder

NOTE:

THIS INFORMATION IS CONFIDENTIAL AND WILL BE DESTROYED ONCE APPLICATION FEE IS PROCESSED.

Alberta Transportation

Carrier Services Room 401, 4920 ­ 51 Street Red Deer, Alberta, T4N 6K8 Phone #: 403-340-5444 (Toll Free in Alberta by first dialing 310-0000) Fax #: 403-340-4806

June 8, 2012 Page 18 of 18

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