Broker Authority Application – OP1

APPLICANT INFORMATION

DO YOU NOW HAVE AUTHORITY FROM OR AN APPLICATION BEING PROCESSED BY THE FMCSA, FHWA, OMCS, OR ICC?

Yes

No

If yes, identify the MC/FF Number (or lead docket number):

LEGAL BUSINESS NAME:

DOING BUSINESS AS NAME

(if different from Legal Business Name):

PRINCIPAL PLACE OF BUSINESS (no P.O. Box):

STREET ADDRESS/RTE. NUMBER City State / Province / Region ZIP / Postal Code

TELEPHONE

FAX

MAILING ADDRESS:

Same as Principal Address

Mailing address below:

Address

STREET ADDRESS/RTE. NUMBER City State / Province / Region ZIP / Postal Code

TELEPHONE

FAX

REPRESENTATIVE (person who can respond to inquiries):

NAME

TITLE, POSITION, OR RELATIONSHIP TO APPLICANT

Address

STREET ADDRESS/RTE. NUMBER City State / Province / Region ZIP / Postal Code

TELEPHONE

FAX

USDOT NUMBER (if available; if not, see instructions):

FORM OF BUSINESS (select only one):

CORPORATION

SOLE PROPRIETORSHIP

PARTNERSHIP

State of Incorporation:

Legal Name of Owner:

Legal Name of Each Partner:

TYPE OF OPERATING AUTHORITY

Total Fee + Govt. Fee

(you must submit a filing fee of $300 for each box checked):

CHECK BOX(ES) FOR EACH TYPE OF OPERATING AUTHORITY REQUESTED

Motor Common Carrier of Property (except Household Goods)

Motor Contract Carrier of Property (except Household Goods)

Motor Common Carrier of Household Goods

Motor Contract Carrier of Household Goods

Broker of Property (except Household Goods)

Broker of Household Goods

United States-based Enterprise Carrier of International Cargo (except Household Goods)

United States-based Enterprise Carrier of International Household Goods

INSURANCE INFORMATION

Applicants that will operate commercial motor vehicles must complete this section.

The dollar amounts in parentheses represent the minimum amount of bodily injury and property damage (liability) insurance coverage you must maintain and have on file with the FMCSA.

(Refer to the instructions for information about cargo insurance requirements for motor common carriers and United States-based enterprise carriers, and surety bond/trust fund agreement filings for brokers.)

APPLICANT WILL OPERATE ONE OR MORE VEHICLE(S) HAVING A GROSS VEHICLE WEIGHT RATING (GVWR) OF 10,001 POUNDS OR MORE TO TRANSPORT:

Non-hazardous commodities ($750,000)

Hazardous materials referenced in FMCSA’s insurance regulations at 49 CFR 387.9 ($1,000,000)

Hazardous materials referenced in FMCSA’s insurance regulations at 49 CFR 387.9 ($5,000,000)

APPLICANT WILL OPERATE ONLY VEHICLE(S) HAVING GROSS VEHICLE WEIGHT RATINGS (GVWR) UNDER 10,001 POUNDS TO TRANSPORT:

Any quantity of Division 1.1, 1.2, or 1.3 material; any quantity of Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; or highway route controlled quantities of a Class 7 material as defined in 49 CFR 173.403 ($5,000,000)

Commodities other than those listed above ($300,000)

SAFETY CERTIFICATION

For vehicle-operating applicants only. (Select only one.) If you will operate vehicles of more than 10,001 pounds GVWR and are, thus, subject to pertinent portions of the USDOT’s Federal Motor Carrier Safety Regulations (FMCSRs) at 49 CFR, Chapter 3, Subchapter B (Parts 350-399), you must certify as follows: Applicant has access to and is familiar with all applicable USDOT regulations relating to the safe operation of commercial vehicles and the safe transportation of hazardous materials, and will comply with these regulations. In so certifying, applicant is verifying that, at a minimum, it: (1) Has in place a system and an individual responsible for ensuring overall compliance with FMCSRs. (2) Can produce a copy of the FMCSRs and the Hazardous Materials Transportation Regulations. (3) Has in place a driver safety training/orientation program. (4) Has prepared and maintains an accident register (49 CFR 390.15). (5) Is familiar with DOT regulations governing driver qualifications and has in place a system for overseeing driver qualification requirements (49 CFR 391). (6) Has in place policies and procedures consistent with USDOT regulations governing driving and operational safety of motor vehicles, including drivers’ hours of service and vehicle inspection, repair, and maintenance (49 CFR 392, 395, and 396). (7) Is familiar with, and will have in place on the appropriate effective date, a system for complying with USDOT regulations governing alcohol and controlled substances testing requirements (49 CFR 382 and 40).

EXEMPT APPLICANTS

If you will operate only small vehicles (GVWR under 10,001 pounds) and will not transport hazardous materials, you are exempt from FMCSRs, and must certify as follows: Applicant is familiar with and will observe general operational safety guidelines, as well as any State and local laws and requirements relating to the safe operation of commercial motor vehicles and the safe transportation of hazardous materials.

AFFILIATIONS

Max. file size: 128 MB.

Disclose any relationship you have or have had with any other FMCSA-regulated entity (including entities licensed by the FHWA, OMCS, or ICC) within the past three years. Examples include, but are not limited to, a percentage of stock ownership, a loan, or a management position. If this requirement applies to you, provide the name of the company, MC/FF Number, USDOT Number, and that company’s latest DOT safety rating. If you require more space, attach the information to this application form.

HOUSEHOLD GOODS CERTIFICATIONS

HOUSEHOLD GOODS MOTOR COMMON CARRIER APPLICANTS (including United States-based Enterprise Carriers of International Household Goods) MUST CERTIFY AS FOLLOWS:

Yes

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.

HOUSEHOLD GOODS MOTOR CONTRACT CARRIER APPLICANTS (including United States-based Enterprise Carriers of International Household Goods) MUST CERTIFY AS FOLLOWS:

Yes

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 USC 13101.

HOUSEHOLD GOODS BROKER APPLICANTS MUST CERTIFY AS FOLLOWS:

Yes

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 USC 13101.

SCOPE OF OPERATING AUTHORITY

ONLY 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).

NOTE: All motor carriers must comply with all pertinent Federal, State, local and tribal statutory and regulatory requirements when operating within the United States. Such requirements include, but are not limited to, all applicable statutory and regulatory requirements administered by the U.S. Department of Labor, or by a State agency operating a plan pursuant to Section 18 of the Occupational Safety and Health Act of 1970 (“OSHA State plan agency”). Such re- quirements also include all applicable statutory and regulatory environmental standards and requirements administered by the U.S. Environmental Protection Agency or a State, local or tribal environmental protection agency. Compliance with these statutory and regulatory requirements may require motor carriers and/or individual operators to produce documents for review and inspection for the purpose of determining compliance with such statutes and regulations.

APPLICANT’S OATH

THIS OATH APPLIES TO ALL SUPPLEMENTAL FILINGS TO THIS APPLICATION.

(The signature must be that of the applicant, not a legal representative. Print name in the first blank space.)

Name

Signature:

Title:

(please type or print)

Date

Total Fee + Govt. Fee

Credit Card

Card Details

Cardholder Name

Broker Authority Application – OP1

APPLICANT INFORMATION

REPRESENTATIVE (person who can respond to inquiries):

TYPE OF OPERATING AUTHORITY

INSURANCE INFORMATION

Applicants that will operate commercial motor vehicles must complete this section.

EXEMPT APPLICANTS

HOUSEHOLD GOODS CERTIFICATIONS

SCOPE OF OPERATING AUTHORITY

APPLICANT’S OATH

THIS OATH APPLIES TO ALL SUPPLEMENTAL FILINGS TO THIS APPLICATION.

Us carrier filer

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