Form Ucr 101 - Unified Carrier Registration - Vehicle List 101 - 2017
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2UCR 101 (10/10/2016)
UNIFIED CARRIER REGISTRATION 2017
VEHICLE LIST 101
CARRIER/BUSINESS INFORMATION
USDOT NUMBER
MC OR MX NUMBER
FF NUMBER
TELEPHONE NUMBER
FAX NUMBER
CARRIER FULL LEGAL NAME
EMAIL ADDRESS
DOING BUSINESS AS NAME
(state)
(zip code)
BUSINESS PRINCIPAL LOCATION (street address)
(city)
MAILING ADDRESS (if different from above) (street address)
(city)
(state)
(zip code)
CLASSIFICATION (check all that apply)
MOTOR CARRIER
MOTOR PRIVATE CARRIER
VEHICLE LIST
Use this chart and the one on the reverse of this form to record the vehicles you use exclusively in intrastate transportation of
property, waste, or recyclable material. This data may be maintained in an electronic format.
LICENSE PLATE NUMBER &
VEHICLE MAKE
VEHICLE MODEL
VIN NUMBER
STATE OF ISSUE
PAGE _1_ OF _________
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
OWNER, CARRIER, AUTHORIZED REPRESENTATIVE NAME (print)
TITLE
SIGNATURE
DATE
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