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	Safety Certification for Application (Safety Certification for Application for U.S. DOT Number)
U.S. Department of Transportation Federal Motor Carrier Safety Administration
1. NAME OF MOTOR CARRIER/HM SHIPPER			2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME
3. PRINCIPAL STREET ADDRESS/ROUTE NUMBER			4. MAILING ADDRESS (P O BOX)
5. CITY	6. STATE/PROVINCE	7. ZIP CODE +4	8. MAILING CITY	9. STATE/PROVINCE	10. ZIP CODE +4
11. PRINCIPAL PHONE NUMBER			12. PRINCIPAL FAX NUMBER
13. USDOT NO. 14. MC OR MX NO. 15. DUN & BRADSTREET NO. 16. IRS/TAX ID NO. EIN# SSN# 17. INTERNET E-MAIL ADDRESS 18. SAFETY CERTIFICATIONS (Applicants subject to FMCSRs must complete certification item(s) 18A through 18C). Applicant maintains current copies of all U.S. DOT Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety Standards, and the Hazardous Materials Regulations (if a property carrier transporting hazardous materials), understands and will comply with such regulations, and has ensured that all company personnel are aware of the current requirements. Yes   No Applicant certifies that the following tasks and measures will be fully accomplished and procedures fully implemented before it commences operations in the United States.          1. Driver qualifications: a) The carrier has in place a system and procedures for ensuring the continued qualification of drivers to operate safely, including a safety record for each driver, procedures for verification of proper licensing of each driver and procedures for identifying drivers who are not complying with the safety regulations. Yes   No b) The carrier has procedures in place to review drivers’ employment and driving histories for at least the last 3 years to determine whether or not the individual is qualified and competent to drive safely. Yes   No c) The carrier has established a program to review the records of each driver at least once every 12 months and will maintain a record of the review. Yes   No d) The carrier will ensure that all of its drivers are at least 21 years of age and if applicable possess a valid Commercial Drivers License (CDL). Yes   No          2. Hours of Service: a) The carrier has in place a recordkeeping system and procedures to monitor the hours-of-service performed by drivers, including procedures for continuing review of drivers’ log books, and for ensuring compliance with all operations requirements. Yes   No b) The carrier has ensured that all drivers are knowledgeable of the hours-of-service requirements, and has clearly and specifically instructed the drivers concerning the application to them of the 10-hour, 15-hour, and 60 and 70-hour rules as well as the requirement for preparing daily log entries in their own handwriting for each 24-hour period. Yes   No          3. Drug and alcohol testing: a) The carrier is familiar with the alcohol and controlled substance testing requirements of 49 CFR part 382 and 49 CFR part 40 and has in place a program for systematic testing of drivers. Yes   No   N/A            4. Vehicle condition: a) The carrier has established a system and procedures for inspection, repair and maintenance of its vehicles in a safe condition, and for preparation and maintenance of records of inspection, repair and maintenance in accordance with the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations. Yes   No b) The carrier will ensure that all violations and defects noted on inspection reports are corrected before vehicles and drivers are permitted to continue operation. Yes   No          5. Accident monitoring program:

a) The carrier has in place a program for monitoring vehicle accidents and maintains an accident register in accordance with 49 CFR 390.15.	Yes   No
b) The carrier has established an accident countermeasures program and driver training program to reduce accidents.	Yes   No
6. Production of records:
a) The carrier can and will produce records demonstrating compliance with the safety requirements within 48 hours of receipt of a request from a representative of the USDOT/FMCSA or other authorized Federal or State official.	Yes   No
7. Hazardous Materials (to be completed by carriers of hazardous materials only).
a) The HM carrier has full knowledge of the U.S. DOT Hazardous Materials Regulations and has established programs for the thorough training of its personnel as required under 49 CFR part 172, Subpart H, and 49 CFR 177.816.	Yes   No   N/A
b) The carrier has established a system and procedures for inspection, repair and maintenance of its reusable hazardous materials packages (cargo tanks, portable tanks, cylinders, intermediate bulk containers, etc.) in a safe condition, and for preparation and maintenance of records of inspection, repair and maintenance in accordance with the U.S. DOT Hazardous Materials Regulations.	Yes   No   N/A
c) The HM carrier has established a system and procedures for filing and maintaining HM shipping documents.	Yes   No   N/A
d) The HM carrier has a system in place to ensure that all HM trucks are marked and placarded as required by 49 CFR part 172, Subparts D and F.	Yes   No   N/A
e) The carrier will register under 49 CFR part 107, Subpart G, if transporting any quantity of hazardous materials requiring the vehicle to be placarded.	Yes   No   N/A
8. For Cargo Tank (CT) Carriers of HM
a) The carrier has a system in place to ensure that its cargo tanks are inspected and tested as required by 49 CFR 180 by a facility registered with the U.S. DOT under part 107, Subpart F.	Yes   No   N/A
By signing these certifications, the carrier official is on notice that the representations made herein are subject to verification through inspections in the United States and through the request for and examination of records and documents. Failure to support the representations contained in this application could form the basis of a proceeding to assess civil penalties and/or lead to the revocation of the authority granted.
All applicants must certify as follows:
1. Applicant is willing and able to provide the proposed operations or service and to comply with all pertinent statutory and regulatory requirements and regulations issued or administered by the U.S. Department of Transportation, including operational regulations, safety fitness requirements, motor vehicle safety standards, and minimum financial responsibility requirements.	Yes   No
2. Applicant is willing and able to produce for review or inspection documents which are requested for the purpose of determining compliance with applicable statutes and regulations administered by the U.S. Department of Transportation, including the Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety Standards and Hazardous Materials Regulations, within 48 hours of any written request.	Yes   No
3. Applicant is not presently disqualified from operating commercial vehicles in the United States pursuant to the Motor Carrier Improvement Act of 1999 or any other law.	Yes   No
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 administered 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. Environmental 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.
19. 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 ________________________________