Fillable Form Ucr 100 - Unified Carrier Registration Form

UNIFIED CARRIER REGISTRATION 2017

UCR 100 (10/10/2016)

REGISTRATION YEAR

BASE STATE

2017

Purpose:

Individuals and companies that operate commercial motor vehicles in interstate or international commerce use this form to register their

business with their base state of Virginia and pay an annual fee based on the size of their fleet.

Instructions:

Follow the instructions on the reverse of this application. Mail the completed form to Motor Carrier Services at the above address or fax

to (804) 367-1058.

SECTION 1: GENERAL INFORMATION

USDOT NUMBER

MC or MX NUMBER

FF NUMBER

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

LEGAL NAME

EMAIL ADDRESS

DOING BUSINESS AS NAME

STREET ADDRESS FOR PRINCIPAL PLACE OF BUSINESS

CITY

STATE

ZIP CODE

MAILING STREET ADDRESS (If different from above)

CITY

STATE

ZIP CODE

PRIMARY CONTACT PERSON NAME (If different from above)

PRIMARY CONTACT PERSON EMAIL ADDRESS

CONTACT TELEPHONE NUMBER

(

)

SECTION 2: CLASSIFICATION (Check all that apply)

Motor Carrier

Motor Private Carrier

Broker

Leasing Company

Freight Forwarder

SECTION 3: BROKER, LEASING COMPANY AND FREIGHT FORWARDER FEES DUE

Note: If your company is also a motor carrier or motor private carrier, skip this section and go to Section 4.

Brokers, Freight Forwarders or Leasing Companies (not a motor carrier combination) should submit an amount due of $76.00 and skip to Section 7

Certification. You may pay by check or money order made payable to DMV.

SECTION 4: NUMBER OF VEHICLES FOR MOTOR CARRIER OR MOTOR PRIVATE CARRIER

CHECK

OPTION A - The number of vehicles shown below

OPTION B - The number of vehicles shown below is the total number owned

ONE

is from Section 26 of my last reported MCS-150/

and operated for the 12-month period ending June 30.

MCSA-1.

See Instructions. Section 4, Options.

COLUMN C

COLUMN A

COLUMN D

Line

Number of Motor Coaches, School Buses, Mini-Buses,

Number of Straight Trucks and Tractors

Total Vehicles

Passenger Vans, and Limousines

You may subtract the number of property carrying vehicles on line 1, Column A that are used only in intrastate commerce

You are required to maintain a list of these vehicles. See Instructions, Section 4, Line 2.

Subtract the number of vehicles on line 1, Column C that have a vehicle capacity of 10 or less passengers, including the

driver.

You may add vehicles that are not included on line 1 and are:

(a) commercial motor vehicles operating solely in intrastate commerce (see instructions for definition of commercial

vehicles)

(b) used in commerce to transport passengers or property for compensation and have a GVWR or GVW of 10,000 or

less, or have a passenger capacity of 10 or less (including the driver)

TOTAL number of vehicles (line 1 minus line 2 plus line 3)

SECTION 5: FEE TABLE FOR MOTOR CARRIER AND MOTOR PRIVATE CARRIER

Number of vehicles

0 - 2

3 - 5

6 - 20

21 - 100

101 - 1000

1001 or more

Amount due

$ 76.00

$ 227.00

$ 452.00

$ 1,576.00

$ 7,511.00

$ 73,346 .00

SECTION 6: FEE DUE FOR MOTOR CARRIER AND MOTOR PRIVATE CARRIER

NOTE: In our continuing effort to safeguard customer information, DMV does not accept credit card payments by mail or email. You may still pay with a

credit card by having a Motor Carrier Services Representative contact you. We continue to accept checks and money orders via mail. Customers

can also use the Unified Carrier Registration portal at

to register and pay their fees.

Contact me for credit card payment

Determine the amount due by comparing the total number of

TELEPHONE NUMBER

AMOUNT DUE

→

vehicles entered on line 4 with the chart in Section 5.

(

)

Enter contact number here

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. I understand that it is unlawful to knowingly make a false statement on this application and that any violation may be

prosecuted as a Class 5 felony (Virginia Code §18.2-434 and 46.2-105).

NAME OF OWNER OR AUTHORIZED REPRESENTATIVE (Print)

TITLE

DATE (mm/dd/yyyy)

OWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE