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Legal Business Name

Doing Business As Name(s) (if different from Legal Business Name)

Is the Applicant's Principal Place of Business Address the same as the Application Contact's Address?

Yes

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Principal Place of Business Address (P.O. Box will not be accepted)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Employer Identification Number (EIN) or Social Security Number (SSN) Note: Sole proprietor owner/operators who do not have an EIN may submit their Social Security Number (SSN) instead of the EIN but are encouraged to obtain an EIN rather than using an SSN to register for a USDOT Number.

Form of Business (Select the business form that applies)

Sole Proprietor

Partnership

Limited Liability Company

Corporation (State of Incorporation)

Limited Liability Partnership

Business Formation State

State

Ownership and Control

Owned/controlled by citizen of United States

Owned/controlled by citizen of Canada

Owned/controlled by citizen of Mexico

Owned/controlled by citizen of other foreign country

First Name

Last Name

Title

Business Email

Will the Applicant transport Non-Hazardous Materials across state lines, otherwise known as Interstate Commerce?

Yes

Please select all classifications of cargo that the Applicant will transport or handle.

General Freight

Household Goods

Metal: Sheets, Coils, Rolls

Motor Vehicles

Drive Away/Tow Away

Logs, Poles, Beams, Lumber

Building Materials

Mobile Homes

Machinery, Large Objects

Fresh Produce

Liquids/Gasses

Intermodal

Passengers

Oil Field Equipment

Livestock

Grain, Feed, Hay

Coal/Coke

Meat

Garbage, Refuse, Trash

US Mail

Chemicals

Commodities Dry Bulk

Refrigerated Food

Beverages

Paper Product

Utility

Farm Supplies

Construction

Water Well

Other

Please provide the number of (non-CMVs) non commercial vehicles you plans to operate.

Vehicle Types - What type of Commercial motor vehicle(s) will you or the business operate?

Please provide the number of Commercial Motor Vehicles the Applicant will operate in Canada or Mexico?

Please provide the number of Commercial Motor Vehicles the Applicant will operate solely in Interstate Commerce.

Please provide the number of Commercial Motor Vehicles the Applicant will operate solely in Intrastate Commerce.

What is the number of drivers who will operate as Interstate ?

What are the number of drivers with a Commercial Driver's License (CDL), Licencia Federal de Conductor (LFC), or a valid Canadian License Class 1, 2, 3, or 4 (or Class A, B, C, or D if licensed in Ontario)?

What are the number of drivers who will operate in Canada or Mexico?

I , certify that I am familiar with the Federal Motor Carrier Safety Regulations and, if applicable, the Federal Hazardous Materials Regulations, and the Federal Motor Carrier Commercial Regulations. Under penalties of perjury, under the laws of the United States of America, I certify that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under 18 U.S.C. § 1001 by imprisonment up to 5 years and fines up to $250,000 for each offense. Additionally, these statements are punishable as perjury under 18 U.S.C. § 1621, which provides for fines up to $250,000 or imprisonment up to 5 years for each offense. I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State offense involving the distribution or possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits, either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, formerly Pub. L. 100-690, Title V, Section 5301, Nov. 18, 1988, 102 Stat.4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002(d), Nov. 29, 1990, 104 Stat. 4827 (21 U.S.C. § 826). E-Signature (Application Password)

Does the Applicant certify it is not currently disqualified from operating commercial motor vehicles in the United States?

Yes

Does the Applicant certify it understands that the agent(s) for service of process designation will be deemed the applicant’s official representative(s) in the United States for receipt of filings and notices in administrative proceedings under 49 U.S.C. § 13303, and for receipt of filings and notices issued in connection with the enforcement of any Federal statutes or regulations?

Yes

Does the Applicant certify that the carrier is not prohibited from filing this application because its FMCSA registration is currently under suspension, or was revoked less than 30 days before filing the application?

Yes

If the Applicant's registration is currently revoked, does the Applicant certify the deficiencies cited in the revocation proceeding have been corrected?

Yes

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