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I AM APPLYING FOR THE FOLLOWING AUTHORITY(S) 
FREIGHT or PASSENGER 

Common Contract Broker (except Household Goods) 
Broker (of Household Goods) Freight Forwarder

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I WILL BE TRANSPORTING THE FOLLOWING COMMODITIES:
(Freight carriers only)

General commodities, non-hazardous commodities 
(Minimum of $750,000 BI&PD required)

Household goods 
(Minimum of $750,000 BI&PD required)

Hazardous materials that require a minimum of $1,000,000 BI&PD 
(HAZMAT certificate application required)

Hazardous materials that require a minimum of $5,000,000 BI&PD 
(HAZMAT certificate application required)

NOTE: Common Carriers must have a minimum of $10,000 cargo insurance.

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FOR PASSENGER CARRIERS ONLY

Passenger carriers transporting 15 passengers or less 
(Minimum of $1,500,000 BI&PD required)

Passenger carriers transporting more than 15 passengers.  
(Minimum of $5,500,000 BI&PD required)

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Will operate vehicles having Gross Vehicle Weight Ratings 
(GVWR) of 10,000 pounds or more.

Will operate vehicles having GVWR under 10,000 pounds.

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APPLICANT NAME 
* Required

DOING BUSINESS AS: 

SSN or EIN: 

PHYSICAL ADDRESS, CITY, STATE & ZIP CODE

MAILING ADDRESS, CITY, STATE & ZIP CODE

TELEPHONE:    * Required  xxx-xxx-xxxx

FAX NUMBER:   * Required xxx-xxx-xxxx

 EMAIL ADDRESS:
* Required

BUSINESS TYPE: 
Individual; Partnership; Corporation (State - ); LLC (State -

ACTUAL COMMODITIES TO BE TRANSPORTED:

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YOU MUST ANSWER "YES" OR "NO" TO THE FOLLOWING QUESTIONS:

1. Do you have ICC/FHWA Authority now?
(Yes) or (No)  MC#

2. Do you or anyone connected with company now have interest in any other ICC/FHWA regulated carrier or broker?
(Yes) or (No)  If "YES" list Name of Company and MC#

3. Have you ever had a DOT Safety Audit?
(Yes) or (No) 

PRESENT DOT NUMBER (IF ANY)

Safety Rating (If any)  None Satisfactory Conditional Unsatisfactory

4. (Yes) or (No) Have you been convicted after September 1, 1989, of distribution or possession of a controlled substance?

5. (Yes) or (No) Will your operations be conducted in compliance with the DOT rules and regulations or safety?

6. (Yes) or (No) Are you domiciled, owned, or controlled by persons in Mexico?

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Would you like us to tell you how much it will cost you for your State Permits?

YES! - please send me a - FREE - State Permit Quote.
(Note: State Permits are not included in the price of the authority.  A detailed quote will be sent to you according to the state specifications you designate below.)

#Number of Vehicles: Gross Vehicle Weight:   

Single State Registration: 

Select participating states...
AL,  AR,  CA,  CO,  CT,  GA,  ID,  IL,  IN,  IA, 
KS,  KY,  LA,  ME,  MA,  MI,  MN,  MS,  MO,  MT, 
NE,  NH,  NM,  NY,  NC,  ND,  OH,  OK,  RI,  SC, 
SD,  TN,  TX,  UT,  VA,  WA,  WV,  WI.

Order ALL 48 States SSRS

SSRS NOTE: AZ, DE, FL, NJ, MD, NV, OR, PA, VT and WY are not participants in the Single State Registration Program and therefore this credential is not required to travel in these states.  If you are based in a non-participating state we will file your application in a neighboring state to fulfill this requirement. 

IFTA/Mileage Tax Permits:  
IFTA     Base State :  KY; NM; NY; OR (Bond Required)