Fillable Form Ucr-1 - Unified Carrier Registration Form printable pdf download

UNIFIED CARRIER REGISTRATION

STATE OF CONNECTICUT

DEPARTMENT OF MOTOR VEHICLES

UCR-1 REV. 9-2008

UCR SECTION, Room 260

WETHERSFIELD, CT 06161-1015

See Reverse for Instructions

On The Web At ct.gov/dmv

UNIFIED CARRIER REGISTRATION - Year ___________

DMV VALIDATION ABOVE

SECTION 1. GENERAL INFORMATION

US DOT NUMBER

MC 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

Check or Money

Brokers, freight forwarders and leasing companies (not a motor carrier combination), please submit the amount due of $39.00 in the form of

Order. Make checks payable to "DMV" and go to Section 7.

SECTION 4 NUMBER OF MOTOR VEHICLES - MOTOR CARRIER AND PRIVATE MOTOR CARRIER

(CHECK ONLY ONE BOX)

The number of vehicles shown below have been taken from section 26 of your last reported MCS-150 form.

The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30.

NUMBER OF STRAIGHT

NO. OF MOTOR COACHES, SCHOOL BUSES,

NUMBER OF TRAILERS

TOTAL

TRUCKS AND TRACTORS

MINI-BUSES, VANS AND LIMOUSINES

(COLUMN B)

(COLUMN D)

(COLUMN A)

(COLUMN C)

(Optional) Under this program you have the option to delete any vehicles in Column A or B above that you have

reported on your MCS 150 that are used only in intrastate commerce. (See instructions)

(

)

(Optional) You may add vehicles that (a) have not been shown on the MCS 150 form that are defined as

commercial motor vehicles operating solely in intrastate commerce; and/or (b) other self-propelled motor vehicles

operating in intrastate or interstate commerce that:

•

Have a gross vehicle weight rating or gross vehicle weight of 10,000 lbs. or less, or a passenger capacity of 10

less, including the driver;

•

Used on the highways in commerce; and

•

To transport passengers or property for compensation. (See instructions for definition of commercial motor vehicle)

3. TOTAL NUMBER OF VEHICLES (Total (Column D) minus LINE 1 plus LINE 2)

SECTION 5 FEE TABLE

(CHECK ONLY ONE BOX)

0-2 VEHICLES ($39.00 amount due)

21-100 VEHICLES ($806.00 amount due)

3-5 VEHICLES ($116.00 amount due)

101-1000 VEHICLES ($3,840.00 amount due)

6-20 VEHICLES ($231.00 amount due)

1001 or MORE VEHICLES ($37,500.00 amount due)

SECTION 6 FEES DUE

MOTOR CARRIER AND MOTOR PRIVATE CARRIER ONLY - Using the number of vehicles in Section 4, Line 3 above, enter the

Amount Due from the table above. Note: Payment can be made in the form of Check or Money Order. Make checks payable to "DMV"

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.)

NAME OF OWNER OR AUTHORIZED REPRESENTATIVE (Please Print)

DATE

SIGNATURE

TITLE

Form Ucr-1 - Unified Carrier Registration Form

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