United States Department Of Transportation 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)



















19. IRS/TAX ID NO.

21. COMPANY OPERATION (Circle either Registrant, or up to one Carrier and one Shipper Operation)


23. OPERATION CLASSIFICATION (Circle All that Apply)
24. CARGO CLASSIFICATIONS (Circle All that Apply)
25. HAZARDOUS MATERIALS CARRIED OR SHIPPED (Check All that Apply) C-CARRIED S-SHIPPED B(BULK)-IN CARGO TANKS NB(NON-BULK)-IN PACKAGES
DIV 1.1 DIV 2.3D DIV 6.1SOLID
DIV 1.2 CLASS 3 CLASS 7
DIV 1.3 CLASS 3A HRCQ
DIV 1.4 CLASS 3B CLASS 8
DIV 1.5 COMB LIQ CLASS 8A
DIV 1.6 DIV 4.1 CLASS 8B
DIV 2.1 DIV 4.2 CLASS 9
DIV 2.1LPG DIV 4.3 ELEVATED TEMP MAT
DIV 2.1(METHANE) DIV 5.1 INFECTIOUS WASTE
DIV 2.2 DIV 5.2 MARINE POLLUTANTS
DIV 2.2A (AMMONIA) DIV 6.2 HAZARDOUS SUB(RQ)
DIV 2.3A DIV 6.1A HAZARDOUS WASTE
DIV 2.3B DIV 6.1B ORM  
DIV 2.3C DIV 6.1POISON
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+
27. DRIVER INFORMATION INTERSTATE INTRASTATE
 
28. IS YOUR U.S. DOT NUMBER REGISTRATION CURRENTLY REVOKED BY THE
FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION?                                                                                                     Yes No
    

1.    2.
                                                         (Please print Name)                                                                             (Please print Name)












                                                                            INITIAL                                                                                         RENEWAL



    
    
35. IF YOUR ANSWER TO QUESTION 34 IS YES, CHECK THE STATE(S) IN WHICH YOU HAVE THE PERMIT
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)

       
11/24/2014