Form Op-1 - Application For Motor Property Carrier And Broker Authority Page 15
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16FORM OP-1 Revised 01/10/2017
OMB No.: 2126-0016 Expiration: 01/31/2020
Section
8
APPLICANT’S OATH
38. THIS OATH APPLIES TO ALL SUPPLEMENTAL FILINGS TO THIS APPLICATION.
(The signature must be that of the applicant, not a legal representative. Print name in the first blank space.)
, verify under penalty of perjury, under the laws of the United States of America, that
I,
(please type or print name)
all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and
authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal
violations punishable under
18 USC 1001
by imprisonment up to 5 years and fines up to $10,000 for each offense. Additionally, these
misstatements are punishable as perjury under
18 USC
1621, which provides for fines up to $2,000 or imprisonment up to 5 years for
each offense.
I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, a, of
any Federal or State offense involving the distribution or possession of a controlled substance, or that if I have been so convicted, I am
not ineligible to receive Federal benefits, either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse
Act of 1988
(21 USC
862).
Finally, I certify that the applicant is not domiciled in Mexico, or owned or controlled by persons of that country. (Note: This portion of
the Applicant’ s Oath does not pertain to applicants that are U.S.-based enterprises owned or controlled by persons of Mexico seeking to provide
truck services for the transportation of international cargo.)
Signature:
Title:
Date:
(please type or print)
PAYMENT INSTRUCTIONS
EACH TYPE OF OPERATING AUTHORITY REQUESTED IN SECTION 2 OF THE APPLICATION FORM REQUIRES A $300
PROCESSING FEE. THIS FEE IS NON-REFUNDABLE.
Calculate the total amount due as follows:
× $300 =
Number of boxes
Total payment due
checked in Section 2
Select payment method:
CHECK OR MONEY ORDER — Make payable to FMCSA in United States currency. Payment must be drawn upon funds deposited in
a bank located in the United States.
CREDIT CARD — Complete the Credit Card Payment Authorization below.
Credit Card Payment Authorization
Select Credit Card:
Credit Card Number:
Expiration Date:
VISA
MasterCard
Name (exactly as it appears on card):
Payment Amount:
Credit Card Billing Address
Street Name and Number:
City:
State/Province:
Zip Code:
Signature:
Payment Date:
FORM OP-1 • Page 5 of 6
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