Appendix A to Part 367 Appendix A to Part 367—Uniform Application for Single State Registration for Motor Carriers Registered with the Secretary of Transportation

Motor Carrier Identification Numbers:

FMCSA MC No.(s.)

US DOT No.

Applicant (Identical to name on FMCSA order):

Name:

D/B/A

Principal Place of Business Address: ¹

¹ A principal place of business is a single location that serves as a motor carrier's headquarters and where it maintains or can make available its operational records.

Street

City

State

Zip

Mailing Address if Different From Business Address Above:

Street

City

State

Zip

Type of Registration:

[] New Carrier Registration— The motor carrier has not previously registered.

[] Annual Registration— The motor carrier is renewing its annual registration.

[] Supplemental Registration— The motor carrier is adding additional vehicles or States of travel after its annual registration.

[] New Registration State Selection— The motor carrier has changed its principal place of business or its prior registration State has left the registration program. The prior registration State was __________.

[] Additional States not registered in prior years. List

Type of Motor Carrier: (Check one)

[] Individual [] Partnership [] Corporation

If corporation, give State in which incorporated:__________

List names of partners or officers:

Name:

Title:

Name:

Title:

Name:

Title:

Type of FMCSA Registered Authority:

Permanent Certificate or Permit [] Temporary Authority (TA) [] Emergency Temporary Authority (ETA) []

FMCSA Certificate(s) or Permit(s):

[] FMCSA Authority Order(s) attached for initial registration.

[] FMCSA Authority Order(s) attached for additional grants received.

[] No change from prior year registration.

Proof of Public Liability Security:

[] The applicant is filing, or causing to be filed, a copy of its proof of public liability security submitted to and accepted by the FMCSA under 49 CFR part 387, subpart C.

[] The applicant has filed, or caused to be filed, a copy of its proof of public liability security submitted to and accepted by the FMCSA under 49 CFR part 387, subpart C, and the security remains in effect.

FMCSA Approved Self-Insurance or Other Securities:

[] FMCSA Insurance order attached for new carrier registration. (Check one when completing for annual registration.)

[] The FMCSA Order approving the self-insurance plan or other security is still in full force and effect, and the carrier is in full compliance with all conditions imposed by the FMCSA Order.

[] The motor carrier is no longer approved under a self-insurance plan or other security, and the motor carrier will file, or cause to be filed, a copy of proof of public liability security with this application in the registration State.

Hazardous Materials: (Check one)

[] The applicant will not haul hazardous materials in any quantity.

[] The applicant will haul hazardous materials that require the following limits in accordance with Title 49 CFR 387.303:

(Check one)

[] Public Liability and Property Damage Insurance of $1 million.

[] Public Liability and Property Damage Insurance of $5 million.

Process Agents:

[] FMCSA Form No. BOC-3 or blanket designation attached for new registration.

[] FMCSA Form No. BOC-3 or blanket designation attached reflecting changes of designation of process agents.

[] No change from prior year registration.

Certification:

I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration State.)

Name (Printed)

Signature

Title

Telephone Number

Date

[58 FR 28933, May 18, 1993. Redesignated at 61 FR 54707, Oct. 21, 1996, as amended at 62 FR 15420, Apr. 1, 1997]