Form Ucr-2 - Unified Carrier Registration Form With Instructions
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2UNIFIED CARRIER REGISTRATION FORM—UCR-2
VEHICLES OWNED AND OPERATED FOR
THE 12 MONTH PERIOD ENDING June 30, 2016
UCR REGISTRATION YEAR 2017
(NOTE: this form is provided to assist you in maintaining required information. Carriers may also submit the requested data
in electronic format or in a printout attached to this form. Contact Nebraska DMV for acceptable data formats.)
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
SECTION 3. VEHICLE LIST
The above described carrier hereby declares that the following vehicles are THE TOTAL NUMBER OWNED AND OPERATED
FOR THE 12 MONTH PERIOD ENDING June 30, 2016.
MAKE
MODEL/GVWR/
LICENSE PLATE
VIN NUMBER
Number of Passengers
NUBER/STATE
A:
STRAIGHT TRUCKS
AND TRACTORS
B: MOTOR COACHES,
SCHOOL BUSES, MINI-
BUSES, VANS, AND
LIMOUSINES
Use reverse side if needed.
SECTION 4. 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 Nebraska.
Name of Owner or Authorized Representative (Printed)
Date
Signature
Title
Revised 8/2016
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