MCSA-1576
MCMIS COMPANY SAFETY PROFILE ORDER FORM
A. SPECIFY COMPANY INFORMATION
Please provide the following information for each company profile.
If ordering more than one profile, provide information for the additional companies on a separate sheet of paper.
_____________________________________
COMPANY NAME:
__________________________________
COMPANY STREET ADDRESS:
________________________________
COMPANY CITY:
STATE: _________ ZIP CODE: __________
________________
COMPANY MC #:
_____________________
COMPANY US DOT #:
B. PROVIDE YOUR MAILING ADDRESS
CONTACT NAME: _____________________________________________________
COMPANY NAME: _____________________________________________________
STREET: _____________________________________________________________
CITY: _____________________________ STATE: ___________________ ZIP CODE: ____________
TELEPHONE NUMBER: __________________ DATE: ________________ E-MAIL: ____________________________
C. CALCULATE COST
COST OF HARD COPY COMPANY SAFETY PROFILE: $27.50 (This is a non-refundable processing charge)
COST OF SUBSCRIPTIONS: MONTHLY $330; QUARTERLY $110; SEMI-ANNUAL $55 (NO DISCOUNTS ON SUBSCRIPTIONS)
*Less discount based on total number of CSPs ordered and shipped at the same time to a single location.
________________ x
$ _______________________
$27.50
MEDIA
# of CSPs ordered
Initial Cost
Paper
— $ _______________________
15%
20%
25%
Discount
2-6 Profiles
7-12 Profiles
13+ Profiles
E-mail (Please Specify:)
________________________
AMOUNT OF CHECK
$ _______________________
(case-sensitive e-mail address)
Make check payable to: Federal Motor Carrier Safety Administration
D. SEND ORDER FORM AND CHECK TO:
Department of Transportation
Federal Motor Carrier Safety Administration
Office of Registration and Safety Information
FMCSA Data Dissemination Program
1200 New Jersey Ave., SE
Washington, DC 20590