Unified Carrier Registration Form - 2016
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1Year 2016
UNIFIED CARRIER REGISTRATION FORM -
To register online go to
SECTION 1. GENERAL INFORMATION
USDOT Number
MC or MX Number
FF Number
Telephone Number
Fax Number
Legal Name
E-Mail Address
Doing Business Under The Following Name (DBA)
Principal Place Of Business Street Address (See Instructions)
Principal Business City
Principal Business State
Zip Code
Mailing Street Address
Mailing City
Mailing State
Mailing Zip Code
SECTION 2. CLASSIFICATION – Check All That Apply
Motor Carrier
Motor Private Carrier
Broker
Leasing Company
Freight Forwarder
SECTION 3. FEES DUE-BROKERS, FREIGHT FORWARDERS AND LEASING COMPANIES ONLY
Note: If your company is also a motor carrier or motor private carrier, skip this section and go to section 4.
Brokers, freight forwarders and leasing companies (not combined with a motor carrier entity), please submit the amount due of $76 in
the form of payment acceptable by your base state and go to Section 7.
SECTION 4. NO. OF MOTOR VEHICLES– MOTOR CARRIER & MOTOR PRIVATE CARRIER
Check only one box:
Option A
The number of vehicles shown below has been taken from section 26 of your last reported MCS-150/MCSA-1 form.
Option B
The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30, 2015.
See Instructions for additional requirements if you select Option B.
NUMBER OF MOTOR COACHES, SCHOOL
TOTAL
LINE
NUMBER OF STRAIGHT TRUCKS
BUSES, MINI-BUSES, VANS AND LIMOUSINES
NO.
AND TRACTORS (COLUMN A)
(COLUMN B)
(COLUMN D)
(COLUMN C)
1.
Subtract:
(
)
(A) The number of vehicles on Line 1 in Column C above that has a vehicle capacity of 10 or less
passengers, including the driver.
2.
(B) (Optional)The number of vehicles on Line 1 in Column A above that are used exclusively in
intrastate transportation. You are required to maintain a list of vehicles excluded under this
(
)
option. See Instructions for additional requirements if you select this option.
(Optional) Add a number of vehicles not shown on Line 1 above that are:
(A) Commercial motor vehicles operating exclusively in intrastate commerce. (See instructions for
definition of commercial motor vehicle.)
3.
(B) Used in commerce to transport passengers or property for compensation and have a GVWR or
GVW of 10,000 lbs or less, or a passenger capacity of 10 or less, including the driver.
Total Number of Vehicles (Line 1 minus Line 2 plus Line 3)
4.
SECTION 5. FEE TABLE
Number of
Number of Vehicles
Amount Due
Number of Vehicles
Amount Due
Amount Due
Vehicles
$76
$452
0-2
6-20
101-1000
$7,511
3-5
$227
21-100
$1,576
1001 or more
$73,346
SECTION 6. FEES DUE – MOTOR CARRIER & MOTOR PRIVATE CARRIER
Using the number of vehicles in Section 4, Line 4 above, enter the Amount Due from the table above.
$
Note: See last page of this pamphlet for the types of payment your selected base state will accept.
SECTION 7. 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 registration state.)
Date
Name Of Owner Or Authorized Representative (Printed)
Title
Signature
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