Package Form Please Fill out the Form Below and Select Package you would like. Order Form Business Name * Business Structure DBA (Doing Business as) LLC Individual INC Physical Address * Physical Address Physical Address Physical Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Mailing Address (PO Box/Street, if different) * Mailing Address (PO Box/Street, if different) Mailing Address (PO Box/Street, if different) Mailing Address (PO Box/Street, if different) City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone (Public Information) Cell / Alternate (Not Public) Fax (Not Public) Email *EIN OR SS# required for all applications EIN (Federal Tax ID #) Owner's Social Security # Single Packages Product USDOT Number Only $75 BOC-3 Process Agent Only $50 USDOT Number & UCR Registration Product 1-2 Trucks $175 3-5 Trucks $335 6-20 Trucks $575 USDOT Number, MC Number, UCR Registration & BOC -3 Product 1-2 Trucks $580 3-5 Trucks $740 6-20 Trucks $980 Truck Information - Please complete if adding KYU # or New Mexico, Not required for USDOT # Required for KYU and New Mexico Make Year Unit # VIN # - Full 17 Digits GVWR License Plate # Required For New Mexico State Required For New Mexico Add 1 Truck Remove 1 Truck USDOT Questionnaire Ever had a USDOT Number? Yes No PIN USDOT Number Interstate Intrastate Vehicle Registrant Only Operation Classifications (Check all that apply) Authorized For-Hire Federal Government Private Passengers (Business) Exempt For-Hire State Government Private Passengers (Non-Business) Private Property Local Government U.S. Mail Migrant OtherOther Cargo Classifications (Check all that apply) General Freight Liquids/Gases Chemicals Household Goods Intermodal Containers Dry Bulk Metals; Sheets; Coils; Rolls Passengers Refrigerated Food Motor Vehicles Oil Field Equipment Beverages Drive Away/Tow Away Livestock Paper Products Logs; Poles; Beams; Lumber Grain; Hay; Feed Utility Building Materials Cole; Coke Farm Supplies Mobile Homes Meat Construction Fresh Produce Garbage, Trash, Refuse Water Well Machinery; Large Objects U.S. Mail OtherOther Hazardous Materials? Yes No If YES, enter Div. or Class Number of Trucks Operated - (Please enter the number of trucks for each category) Straight Trucks Owned Trip Leased Term Leased Truck Trailers Owned Trip Leased Term Leased Trailers Owned Trip Leased Term Leased HazMat Cargo Tank Trucks Owned Trip Leased Term Leased HazMat Cargo Tank Trailers Owned Trip Leased Term Leased Motor Coach Owned Trip Leased Term Leased Number of Vehicles carrying number of Passengers ( Including Driver): School Bus: 1-8 Owned Trip Leased Term Leased School Bus: 9-15 Owned Trip Leased Term Leased School Bus: 16+ Owned Trip Leased Term Leased Mini-Bus: 16+ Owned Trip Leased Term Leased Passenger Van: 1-8 Owned Trip Leased Term Leased Passenger Van: 9-15 Owned Trip Leased Term Leased Limousine: 1-8 Owned Trip Leased Term Leased Limousine: 9-15 Owned Trip Leased Term Leased Limousine: 16+ Owned Trip Leased Term Leased Number of Drivers - (Enter # for each type) Within 100 Air-Mile Radius Interstate Intrastate Total Drivers Total CDL Drivers Greater than 100 Air-Mile Radius Interstate Total Drivers Total Drivers Total CDL Drivers Submit
