Divided Record Authority Permit Application Application for Authority to Retain Records At other than the Principal Place of Business in Alberta Traffic Safety Act, Section 62 Section A: Carrier Information New Application Renewal or Amendment Current Permit # Expiry Date National Safety Code (NSC) Number: AB (shown on Safety Fitness Certificate) Name of Applicant(s): (Trade names are not acceptable) Principal Place of Business (where records are maintained and day-to-day operations conducted): (Street address or legal land location; Post Office box number is insufficient) City/Town: Postal Code: Telephone #: Fax #: Mailing Address (if different from above): Provide the address you are using for vehicle registration purposes in Alberta: Contact Person s Name and Title: Name of Safety Officer: Driver License #: Do you hold any other Permits for Divided Record Authority in any Jurisdiction? Yes No If YES, please specify: Jurisdiction: Permit #: Expiry Date: Revised: November 22, 2013 Page 1 of 5
Section B: Application Information The permit holder may retain the originals or copies of the records or direct electronic access to such records, applicable to vehicles registered in Alberta and the drivers of those vehicles, referred to in the following Alberta Regulations: Driver file records Commercial Vehicle Certificate and Insurance Regulation, (AR314/2002) Section 43(1) Daily logs and supporting documentation Drivers Hours of Service Regulation, (AR317/2002) Section 16(1) Truck and Bus Maintenance and vehicle file records Commercial Vehicle Safety Regulation (AR121/2009) Section 37(3) List address(s) where each type of record will be kept. (Add additional pages, if required) (Identify the full addresses such as street or land locations (no box numbers) for each location. Also specify which records will be kept at each address. Include the phone numbers for each location where applicable.) Section C: Description of the Nature of Your Transportation Business (including identification of general types of commodities/loads being moved) (Add additional pages, if required) Revised: July 13, 2012 Alberta Transportation Page: 2 of 5
Section D: Description of Why Current Legislation is Inadequate (Be specific) (Provide an explanation why vehicles are not registered in your base jurisdiction) (Add additional pages, if required) Section E: National Safety Code Compliance 1. Which of the following have you implemented? Written Safety Plan - Commercial Vehicle Certificate and Insurance Regulation, (AR314/2002) Individual Driver Files - Commercial Vehicle Certificate and Insurance Regulation, (AR314/2002) Written Maintenance Plan - Commercial Vehicle Safety Regulation, (AR121/2009) Individual Vehicle Files - Commercial Vehicle Safety Regulation, (AR121/2009) 2. Which of the following reference material have you obtained? (See: http://www.transportation.alberta.ca/3.htm A copy of all relevant legislation (e.g. Hours of Service, Maintenance, Safety, etc.) A copy of your Carrier Profile within the past year A copy of Alberta s Reference Guide for Hours of Service Training Development A copy of Alberta's Education Manual on general transportation compliance Revised: July 13, 2012 Alberta Transportation Page: 3 of 5
Section F: Description of Internal Controls to Ensure Compliance Outline the administrative controls you have in place to ensure records at each location are being retained as required by regulation and in accordance with your policies that are defined in your safety and maintenance programs. Your controls should include at least periodic (at least annual) on-site verification and documentation of findings and subsequent actions taken. (Add additional pages, if required) Section G: Application Requirements You must designate one or more persons located in Alberta, who are responsible for the carrier s: Inspection, maintenance and repair program Name: Phone # Safety program. Name: Phone # Section H: Certification I certify that I understand and agree to abide by the above requirements, and that information provided in this application is true and correct. Print Name Signature Position/Title Date Email Address Revised: July 13, 2012 Alberta Transportation Page: 4 of 5
Payment Form: Safety Permit Application APPLICATION FILING FEE OF $55 (GST if applicable) (PAYMENT IS NON-REFUNDABLE) Applicant s Name: Telephone # ( ) Cell # ( ) Email Address: PAYMENT OPTIONS: Cheque or Money Order Cheque Attached Money Order Attached PAYMENT OPTION: Credit Card (Visa, MasterCard, American Express) Credit Card Credit Card Acceptance Policy Change The Government of Alberta has changed the process for accepting credit card payments to protect the security of cardholder data. As of December 31, 2013, Alberta Transportation can no longer accept credit card numbers in any format by phone, fax, email, or mail. You cannot include the credit card number on the application. Failure to comply with the payment procedures will result in the application not being processed. Once the application is received and reviewed, Carrier Services will contact the applicant in order to process the credit card payment. At the time of the call, you will be required to have the following information: Credit Card Number, Expiry Date, Name of Cardholder and Security Code Number (Indicated on the back of a Visa or MasterCard, or on the front of an American Express card) For further information contact Carrier Services at 403-755-6111 or toll free by first dialing 310-0000. Alberta Transportation Carrier Services Room 401, 4920 51 Street Red Deer, Alberta, T4N 6K8 Phone #: 403-755-6111 (Toll Free in Alberta by first dialing 310-0000) Fax #: 403-340-4806 Revised: November 22, 2013 Page 5 of 5