Combined Motor Carrier Identification Report and HM Permit Application
U.S. Department of Transportation
Federal Motor Carrier
Safety Administration
REASON FOR FILING (Check Only One)
NEW APPLICATION
BIENNIAL UPDATE OR CHANGE
OUT OF BUSINESS NOTIFICATION
REAPPLICATION (AFTER REVOCATION OF NEW ENTRANT)
1. NAME OF MOTOR CARRIER/HM SHIPPER
2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME
3. PRINCIPAL STREET ADDRESS/ROUTE NUMBER
4. PHYSICAL CITY
5. MAILING ADDRESS (P O BOX)
6. MAILING CITY
7. PHYSICAL STATE/PROVINCE
8. PHYSICAL ZIP CODE +4
9. PHYSICAL COLONIA (MEXICO ONLY)
10. MAILING STATE/PROVINCE
11. MAILING ZIP CODE +4
12. MAILING COLONIA (MEXICO ONLY)
13. PRINCIPAL BUSINESS PHONE NUMBER
14. PRINCIPAL CONTACT CELLULAR NUMBER
15. PRINCIPAL BUSINESS FAX NUMBER
16. USDOT NO.
17. MC OR MX NO.
18. DUN & BRADSTREET NO.
19. IRS/TAX ID NO.
EIN#
SSN#
20. INTERNET E-MAIL ADDRESS
21. COMPANY OPERATION
(Circle either Registrant, or up to one Carrier and one Shipper Operation)
A. Interstate Carrier
B. Intrastate Hazmat Carrier
C. Intrastate Non-Hazmat Carrier
D. Interstate Shipper
E. Intrastate Shipper
F. Registrant
22. CARRIER MILEAGE (to nearest 10, 000 miles for Last Calendar Year)
YEAR
23. OPERATION CLASSIFICATION (Circle All that Apply)
Authorized For-Hire
Private Passengers (Business)
U.S. Mail
Local Government
Exempt For-Hire
Private Passengers (Non-Business)
Federal Government
Indian Tribe
Private (Property)
Migrant
State Government
Other
24. CARGO CLASSIFICATIONS
(Circle All that Apply)
GENERAL FREIGHT
MACHINERY,LARGE OBJECTS
COAL/COKE
PAPER PRODUCTS
HOUSEHOLD GOODS
FRESH PRODUCE
MEAT
UTILITY
METAL:SHEETS,COIL,ROLLS
LIQUIDS/GASES
GARBAGE,REFUSE,TRASH
FARM SUPPLIES
MOTOR VEHICLES
INTERMODAL CONT.
U.S. MAIL
CONSTRUCTION
DRIVE AWAY/TOWAWAY
PASSENGERS
CHEMICALS
WATER WELL
LOGS,POLES BEAMS,LUMBER
OIL FIELD EQUIPMENT
COMMODITIES DRY BULK
OTHER
BUILDING MATERIALS
LIVESTOCK
REFRIGERATED FOOD
MOBILE HOMES
GRAIN,FEED,HAY
BEVERAGES
25. HAZARDOUS MATERIALS CARRIED OR SHIPPED
(Check All that Apply)
C-CARRIED S-SHIPPED B(BULK)-IN CARGO TANKS NB(NON-BULK)-IN PACKAGES
C
S
DIV 1.1
B
NB
C
S
DIV 2.3D
B
NB
C
S
DIV 6.1SOLID
B
NB
C
S
DIV 1.2
B
NB
C
S
CLASS 3
B
NB
C
S
CLASS 7
B
NB
C
S
DIV 1.3
B
NB
C
S
CLASS 3A
B
NB
C
S
HRCQ
B
NB
C
S
DIV 1.4
B
NB
C
S
CLASS 3B
B
NB
C
S
CLASS 8
B
NB
C
S
DIV 1.5
B
NB
C
S
COMB LIQ
B
NB
C
S
CLASS 8A
B
NB
C
S
DIV 1.6
B
NB
C
S
DIV 4.1
B
NB
C
S
CLASS 8B
B
NB
C
S
DIV 2.1
B
NB
C
S
DIV 4.2
B
NB
C
S
CLASS 9
B
NB
C
S
DIV 2.1LPG
B
NB
C
S
DIV 4.3
B
NB
C
S
ELEVATED TEMP MAT
B
NB
C
S
DIV 2.1(METHANE)
B
NB
C
S
DIV 5.1
B
NB
C
S
INFECTIOUS WASTE
B
NB
C
S
DIV 2.2
B
NB
C
S
DIV 5.2
B
NB
C
S
MARINE POLLUTANTS
B
NB
C
S
DIV 2.2A (AMMONIA)
B
NB
C
S
DIV 6.2
B
NB
C
S
HAZARDOUS SUB(RQ)
B
NB
C
S
DIV 2.3A
B
NB
C
S
DIV 6.1A
B
NB
C
S
HAZARDOUS WASTE
B
NB
C
S
DIV 2.3B
B
NB
C
S
DIV 6.1B
B
NB
C
S
ORM
B
NB
C
S
DIV 2.3C
B
NB
C
S
DIV 6.1POISON
B
NB
26. NUMBER OF VEHICLES THAT
CAN BE OPERATED IN THE U.S.
Number of Passengers (including the driver)
Straight
Trucks
Truck
Tractors
Trailers
Hazmat Cargo
Tank Trucks
Hazmat Cargo
Tank Trailers
Motor
Coach
School bus
Mini-bus
Van
Limousine
1-8
9-15
16+
16+
1-8
9-15
1-8
9-15
16+
OWNED
TERM LEASED
TRIP LEASED
27. DRIVER INFORMATION
INTERSTATE
INTRASTATE
TOTAL DRIVERS
TOTAL CDL DRIVERS
Within 100-Mile Radius
Beyond 100-Mile Radius
28. IS YOUR U.S. DOT NUMBER REGISTRATION CURRENTLY REVOKED BY THE
FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION? Yes
No
If Yes, enter the U.S. DOT Number with the revoked registration.
29. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S),OFFICERS OR PARTNERS AND TITLES (e.g. PRESIDENT,TREASURER,GENERAL PARTNER,LIMITED PARTNER)
1.
2.
(Please print Name) (Please print Name)
30. WHICH OF THE FOLLOWING HAZARDOUS MATERIAL(S) DOES YOUR COMPANY TRANSPORT, CHECK ALL THAT APPLY:
Highway Route Controlled Quantities(HRCQ) of Radioactive materials
More than 25kg (55 pounds) of a Division 1.1, 1.2, or 1.3 material or a Division 1.5 material that requires placarding
For materials that meet the definition of "material poisonous by inhalation" (TIH) as defined in 49 CFR 171.8: More than 1 liter (1.08 quarts) per package of material meeting the definition of a Hazard Zone A TIH material, a material meeting the definition of a Hazard Zone B TIH material in a bulk package (capacity greater than 405 liters [119 gallons]), or a material meeting the definition of a Hazard Zone C or D TIH material in a bulk packaging that has a capacity greater than 13,248 L (3,500 gallons).
Shipments of compressed or refrigerated liquid methane or liquefied natural gas with a methane content of at least 85% in a bulk packaging that has capacity greater than 13,248L (3,500 gallons)
31. IF YOU CHECK QUESTION 30, ARE YOU APPLYING FOR RENEWING A HM SAFETY PERMIT? PLEASE CHECK ONE:
INITIAL
RENEWAL
32. IF YOUR COMPANY DOES NOT HAVE A U.S.DOT NUMBER, HOW MANY ACCIDENTS AS DEFINED IN 49 CFR 390.5 HAS YOUR COMPANY HAD IN THE PAST 365 DAYS?
33. DOES YOUR COMPANY CERTIFY THEY HAVE A SATISFACTORY SECURITY PROGRAM IN PLACE AS REQUIRED IN 49 CFR PART 385, SUBPART E?
Yes
No
34. IS YOUR COMPANY REQUIRED BY ANY STATE(S) TO HAVE A PERMIT FOR ANY OF THE HAZARDOUS MATERIALS LISTED IN QUESTION 30?
Yes
No
35. IF YOUR ANSWER TO QUESTION 34 IS YES, CHECK THE STATE(S) IN WHICH YOU HAVE THE PERMIT
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
NOTE:
All motor carriers must comply with all pertinent Federal, State, local and tribal statutory and regulatory requirements when operating within the United States. Such requirements include, but are not limited to, all applicable statutory and regulatory requirements administerd by the U.S. Department of Labor, or by a State agency operating a plan pursuant to Section 18 of the Occupational Safety and Health Act of 1970 ("OSHA State plan agency"). Such requirements also include all applicable statutory and regulatory environmental standards and requirements administered by the U.S. Enviromental Protection Agency or a State, local or tribal environmental protection agency. Compliance with these statutory and regulatory requirements may require motor carriers and/or individual operators to produce documents for review and inspection for the purpose of determining compliance with such statutes and regulations.
36. CERTIFICATION STATEMENT (TO BE COMPLETED BY AN AUTHORIZED OFFICIAL)
I,
,certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or the Federal Hazardous Materials Regulations.
(Please print Name) Under penalties of perjury, I declare that the information entered on this report is, to the best of my knowledge and belief, true,
correct, and complete.
Signature
Date
Title
3/7/2013