Appendix A to Subpart A—Uniform
Application for
Motor Carrier Identification Numbers:
FMCSA MC No.(s.)
US DOT No.
Applicant (Identical to name on FMCSA order):
Name:
D/B/A
Principal Place of Business Address:1
Street
City
State
Zip
Mailing Address if Different From Business Address Above:
Street
City
State
Zip
Type of Registration:
[]New
Carrier Registration—The motor carrier has not previously registered.
[]Annual
Registration—The motor carrier is renewing its annual registration.
[]Supplemental
Registration—The motor carrier is adding additional vehicles or
States of travel after its annual registration.
[]New
Registration State Selection—The motor carrier has changed its
principal place of business or its prior
[]Additional
States not registered in prior years List
Type of Motor Carrier:(Check one)
[]Individual
[]Partnership[]Corporation
If corporation, give State in which incorporated:
List names of partners or officers:
Name:
Title:
Name:
Title:
Name:
Title:
Type of FMCSA Registered Authority:
Permanent Certificate or Permit[]
Temporary Authority(TA)[]
Emergency Temporary Authority(ETA)[]
FMCSA Certificate(s) or Permit(s):
[]FMCSA
Authority Order(s) attached for initial registration.
[]FMCSA
Authority Order(s) attached for additional grants received.
[]No
change from prior year registration.
Proof of Public Liability Security:
[]The applicant is filing, or causing to be filed, a copy of its proof of
public liability security submitted to and accepted by the FMCSA under 49 CFR
part 387 subpart C.
[]The applicant has filed, or caused to be filed, a copy of its proof of public liability
security submitted to and accepted by the FMCSA under 49 CFR part 387 subpart C, and the security
remains in effect.
FMCSA Approved Self–Insurance or Other Securities:
[]FMCSA
Insurance order attached for new carrier registration. (Check one when
completing for annual registration.)
[]The FMCSA Order approving the self–insurance plan or other security
is still in full force and effect, and the carrier is in full compliance with
all conditions imposed by the FMCSA Order.
[]The motor carrier is no longer approved under a self–insurance plan
or other security, and the motor carrier will file, or cause to be filed, a
copy of proof of public liability security with this application in the
registration State.
Hazardous Materials:(Check one)
[]The
applicant will not haul hazardous materials in any quantity.
[]The
applicant will haul hazardous materials that require the following limits in
accordance with Title 49 CFR 387.303:
(Check one)
[]Public
Liability and Property Damage Insurance of $1 million.
[]Public
Liability and Property Damage Insurance of $5 million.
Process Agents:
[]FMCSA
Form No. BOC–3 or blanket designation attached for new registration.
[]FMCSA
Form No. BOC –3 or blanket designation attached reflecting changes of
designation of process agents.
[]No
change from prior year registration.
Certification:
I, the undersigned, under penalty for false statement, certify that the
above information is true and correct and that I am authorized to execute and
file this document on behalf of the applicant. (Penalty provisions subject to
the laws of the
Name (Printed)
Signature
Title
Telephone Number
Date
[58 FR 28933,