Form Op-1 - Application For Motor Property Carrier And Broker Authority - U.s. Department Of Transportation Page 16

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OMB No. 2126-0016

Household Goods Certification

SECTION VI

HOUSEHOLD GOODS MOTOR COMMON CARRIER APPLICANTS including United States-based Enterprise Carriers of International Household Goods

must certify as follows:

Applicant is fit, willing, and able to provide the specialized services necessary to transport household goods. This assessment of fitness includes applicant’s general

familiarity with former ICC, FHWA, or OMCS, now FMCSA regulations for household goods movements and also requires an assurance that applicant has or is willing

to acquire the protective equipment and trained operators necessary to perform household goods movements and that applicant will offer arbitration as a means of

settling loss and damage disputes on collect-on-delivery shipments. The proposed operations will serve a useful public purpose responsive to a public demand or need.

YES

HOUSEHOLD GOODS MOTOR CONTRACT CARRIER APPLICANTS including United States-based Enterprise Carriers of International Household Goods

must certify as follows:

Applicant is fit, willing, and able to provide the specialized services necessary to transport household goods. This assessment of fitness includes applicant’s general

familiarity with former ICC, FHWA, or OMCS, now FMCSA regulations for household goods movements and also requires an assurance that applicant has or is willing

to acquire the protective equipment and trained operators necessary to perform household goods movements and that applicant will offer arbitration as a means of

settling loss and damage disputes on collect-on-delivery shipments. The proposed service will be consistent with the public interest and the transportation policy of

49 U.S.C. 10101.

YES

HOUSEHOLD GOODS BROKER APPLICANTS must certify as follows:

Applicant is fit, willing, and able to provide household goods brokerage operations and to comply with all pertinent statutory and regulatory requirements. The involved

services will be consistent with the public interest and the transportation policy of 49 U.S.C. 10101.

YES

NOTE: Applicant may attach a supporting statement to this application to provide additional information about any of the above certifications. This evidence is optional.

Scope of Operating Authority

SECTION VII

Applicants requesting operating authority as a Motor Contract Carrier of Household Goods must complete this section. Check all boxes that apply.

Contracting shippers have one or more of the distinct needs delineated in Interstate Van Lines, Inc., Extension–Household Goods, 5 I.C.C.2d 168 (1988).

Describe briefly the distinct need(s):

Contracts provide for assignment of one or more vehicles for the exclusive use of each shipper in the manner specified in Interstate Van Lines, Inc., Extension–

Household Goods, 5 I.C.C.2d 168 (1988).

Applicant’s Oath

SECTION VIII

This oath applies to all supplemental filings to this application. The signature must be that of the applicant, not the legal representative.

, verify under penalty of perjury, under the laws of the United States of America,

(Print Name)

that 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 U.S.C. 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 U.S.C. 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, 1989, 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 U.S.C. 862).

Finally, I certify that the applicant is not domiciled in Mexico, or owned or controlled by persons of that country. (NOTE: The preceding sentence does not pertain to

applicants that are United States-based Enterprise Carriers of International Cargo and/or Household Goods.)

Title

Signature

Date

3 / 4

Form OP-1

(Revised 8/14/2007)

Expiration Date 1/8/2010