Form Mcs-150 - Motor Carrier Identification Report - U.s. Department Of Transportation

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S.
OMB No. 2126-0013 Expiration Date: 07/31/2012
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the paperwork Reduction Act
unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0013. Public reporting for this collection of information is estimated to be approximately 20 minutes
per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory, and will be provided confidentiality to
the extent allowed by the Freedom of Information Act (FOIA). Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance
Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
U.S. Department of Transportation
Federal Motor Carrier
(Application for USDOT Number)
Safety Administration
REASON FOR FILING (Mark only one)
NEW APPLICATION
BIENNIAL UPDATE OR CHANGES
OUT OF BUSINESS NOTIFICATION
REAPPLICATION (AFTER REVOCATION OF NEW ENTRANT)
1. NAME OF MOTOR CARRIER
2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME
3. PRINCIPAL ADDRESS
4. CITY
5. STATE/PROVINCE
6. ZIP CODE+4
7. COLONIA (MEXICO ONLY)
8. MAILING ADDRESS
9. CITY
10. STATE/PROVINCE
11. ZIP CODE+4
12. COLONIA (MEXICO ONLY)
13. PRINCIPAL BUSINESS PHONE NUMBER
14. PRINCIPAL CONTACT CELL PHONE NUMBER
15. PRINCIPAL BUSINESS FAX NUMBER
17. MC OR MX NO.
16. USDOT NO.
18. DUN & BRADSTREET NO. 19. IRS/TAX ID NO.
EIN
SSN
21. CARRIER MILEAGE (to nearest 10,000 miles for last calender year) YEAR
20. INTERNET E-MAIL ADDRESS
22. COMPANY OPERATION (Mark all that apply)
A.
Interstate Carrier
B.
Intrastate Hazmat Carrier
C.
Intrastate Non-Hazmat Carrier
D.
Interstate Hazmat Shipper
E.
Intrastate Hazmat Shipper
23. OPERATION CLASSIFICATION (Mark all that apply)
D.
Private Passengers (Business)
G.
U. S. Mail
A.
Authorized For-Hire
J.
Local Government
E.
Private Passengers (Non-Business)
H.
Federal Government
B.
Exempt For-Hire
K.
Indian Tribe
F.
Migrant
I.
State Government
C.
Private Property
L.
Other
24. CARGO CLASSIFICATIONS (Mark all that apply)
A.
GENERAL FREIGHT
G.
BUILDING MATERIALS
M.
PASSENGERS
S.
GARBAGE, REFUSE, TRASH
Y.
PAPER PRODUCT
B.
HOUSEHOLD GOODS
H.
MOBILE HOMES
N.
OIL FIELD EQUIPMENT
T.
U.S.MAIL
Z.
UTILITY
C.
METAL:SHEETS, COILS, ROLLS
I.
MACHINERY, LARGE OBJECTS
O.
LIVESTOCK
U.
CHEMICALS
AA.
FARM SUPPLIES
D.
MOTOR VEHICLES
J.
FRESH PRODUCE
P.
GRAIN, FEED, HAY
V.
COMMODITIES DRY BULK
BB.
CONSTRUCTION
E.
DRIVE AWAY/TOWAWAY
K.
LIQUIDS/GASES
Q.
COAL/COKE
W.
REFRIGERATED FOOD
CC.
WATER WELL
F.
LOGS, POLES, BEAMS, LUMBER
L.
INTERMODAL CONT.
R.
MEAT
X.
BEVERAGES
DD.
OTHER
25. HAZARDOUS MATERIALS (CARRIER OR SHIPPER) (Mark all that apply)
(C) CARRIER
(S) SHIPPER
(B) BULK – IN CARGO TANKS
(NB) NON-BULK – IN PACKAGES
C
S
B NB
C
S
B NB
C
S
B NB
C
S
B NB
EE.
HRCQ
A.
DIV 1.1
K.
DIV 2.2D (Ammonia)
U.
DIV 4.2
FF.
CLASS 8
B.
DIV 1.2
L.
V.
DIV 4.3
DIV 2.3A
GG. CLASS 8A
C.
DIV 1.3
M. DIV 2.3B
W.
DIV 5.1
HH. CLASS 8B
D.
DIV 1.4
N.
DIV 2.3C
X.
DIV 5.2
II.
CLASS 9
E.
DIV 1.5
Y.
DIV 6.2
O.
DIV 2.3D
JJ.
ELEVATED TEMP MAT.
F.
DIV 1.6
Z.
DIV 6.1A
P.
Class 3
KK.
INFECTIOUS WASTE
G.
DIV 2.1 (Flam. Gas)
Q.
AA.
DIV 6.1B
Class 3A
LL.
MARINE POLLUTANTS
H.
BB.
DIV 6.1 POISON
DIV 2.1 LPG
R.
Class 3B
MM. HAZARDOUS SUB (RQ)
I.
DIV 2.1 (Methane)
CC.
DIV 6.1 SOLID
S.
COMB LIQ
NN. HAZARDOUS WASTE
J.
DIV 2.2
DD.
CLASS 7
.
T.
DIV 4.1
OO. ORM
26. NUMBER OF VEHICLES THAT WILL BE OPERATED IN THE U.S.
Number of vehicles carrying number of passengers (including the driver)
School Bus
Mini-bus
Passenger
Limousine
Trailers
Straight
Truck
Hazmat Cargo
Motor-
Hazmat Cargo
Van
Trucks
Tractors
Tank Trucks
Tank Trailers
coach
16+
9-15
1-8
1-8
9-15
16+
1-8
9-15
16+
OWNED
TERM LEASED
TRIP LEASED
INTERSTATE
TOTAL CDL DRIVERS
27. DRIVER INFORMATION
INTRASTATE
TOTAL DRIVERS
Within 100-Mile Radius
Beyond 100-Mile Radius
28. IS YOUR USDOT NUMBER REGISTRATION CURRENTLY REVOKED BY THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION?
Yes
No
If Yes, enter your USDOT Number. ____________________________________________________________
29. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S), OFFICERS OR PARTNERS AND TITLES (e.g. president, treasurer, general partner, limited partner)
1.
2.
30. CERTIFICATION STATEMENT (to be completed by authorized official)
I,
,
certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or Federal Hazardous Materials Regulations.
Under penalties of perjury, I declare that the information entered on this report is, to the best of my knowledge and belief, true,
correct, and complete.
Signature ____________________________________________
Date _______________________________
Title ______________________________________________
(Please print)
Form MCS-150 (Revised: 6/12/2007)

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