Hazardous Materials Registration Statement Form - Us Department Of Transportation printable pdf download

Exempted from Paperwork Reduction Act by 49 U.S.C. 5108(i)

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U. S. DEPARTMENT OF TRANSPORTATION

HAZARDOUS MATERIALS REGISTRATION STATEMENT

REGISTRATION YEAR 20_____ - 20_____

(Please Type or Print all Responses)

Initial Registration ____

Renewal of Registration _____

Amendment to Registration _____

Expedited Follow-up ____

_ _ _ _ _ _ _ _ _ _ _ _ _ _

Current Registration #

1. Registrant ________________________________________________________________________________________________

(Company Name)

(Place pre-printed label here if provided and if name and address are correct. Otherwise, provide correct information.)

2. Mailing Address of Principal Place of Business

Street or P.O. Box ____________________________________________________________ City

_________________________

_ _

_ _ _ _ _

_ _ _ _

County ___________________ State

Zip Code

Country ________________________

3. Registrant's US DOT ID Number, ICC Number, or Reporting Railroad Alphabetic Code (if applicable)

US DOT ID #________________________

MC/MX # _______________________

Railroad Alphabetic Code ____________

4. Mode(s) Used to Transport Hazardous Materials:

Highway ____

Rail ____

Water ____

Air ____

5. Business Category (determined by answering a-c):

a) North American Industrial Classification System (NAICS) Code for Primary Commercial Activity:

(enter one six-digit code): __ __ __ __ __ __

b) Using the SBA size standard for the NAICS code entered above, mark one: ____ Small Business as defined by SBA

____ Not an SBA Small Business

c) Not-For-Profit Organization (under 26 U.S.C. 501(a)):

Yes ____

No ____

6. Registration Fees

See table of fees on page 12. All fees include the appropriate processing fee.

Total Amount Due for this Registration:_________________

Make check or money order in U.S. funds, drawn on a U.S. bank, and payable to “U.S. Department of Transportation,"

and identified as payment for the "Hazmat Registration Fee."

Method of Payment

(check one)

Check ___ Money Order ___ Credit/Debit* Card: ___

VISA ___

MasterCard ___

American Express ___ Discover ___

* For Debit Card payments, see "Payment Options," page 10.

Credit/Debit Card Users Please Provide the Following Information:

Card Number:

Expiration Date:

Name as it appears on the card ___________________________________________

Authorized Signature _____________________________________________________

Cardholder acknowledges ordering goods or services in the amount of the total shown hereon

and agrees to perform the obligations set forth in the Cardholder’s agreement with the issuer.

Card statement will list this payment as “US DOT Hazmat Regis.”

NOTE: If a Small Business or Not-for-Profit Organization completing an expedited registration,

do not resubmit card information here.

Form DOT F 5800.2

(Revised 3/04)

Supercedes all versions revised before 3/03.

THIS FORM MAY BE REPRODUCED

Hazardous Materials Registration Statement Form - Us Department Of Transportation

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