Number of Vehicles Owned:

Number of Straight trucks
Number of Truck Tractors
Number of Trailers
Number of Hazmat cargo tank trailers
Number of Hazmat cargo tank trucks

Number of Vehicles Term Leased:

Number of Straight trucks
Number of Truck Tractors
Number of Trailers
Number of Hazmat cargo tank trailers
Number of Hazmat cargo tank trucks

Number of Vehicles Trip Leased:

Number of Straight trucks
Number of Truck Tractors
Number of Trailers
Number of Hazmat cargo tank trailers
Number of Hazmat cargo tank trucks

Drivers

Total Number of Drivers subject to safety regulations:
Number of CDL Drivers:
Number of drivers that drive intrastate only:
Number of intrastate drivers that drive beyond 100 air mile radius:
Carrier Mileage (to nearest 10,000 miles last calendar year):
What year was this: :

States You Intend to Pass Through Over the Next 12 Months (only 38 states participate in the SSRS program):

Alabama, Arkansas, California, Colorado, Conn., Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana,
Maine, Mass., Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, N.H, N.M., New York, N.C., N.D.,
Ohio, Oklahoma, R.I., S.C., S.D., Tenn., Texas, Utah, Virginia, Wash., W.V., Wisconsin

(Please List All States From the Above List and The Number of Vehicles That Will Operate In Each)



I hereby certify that I am familiar with the Federal Motor carrier Safety Regulations and/or the Federal Hazardous Materials Regulations.  Under penalties of perjury, I hereby declare that the information entered on this form is, to the best of my knowledge and belief, true, correct, and complete.  I hereby authorize DOTAuthority.com, Inc. to make my SSRS filing for the year(s) ending   for an additional fee of $149 and I agree to submit to DOTAuthority.com, Inc or its agent,. all state fees which are due based on my answers above.

Yes                Initial here

No, just do my Interstate Authority Application

Insurance Information:

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 federal government.

I will operate vehicles having Gross Vehicle Weight Ratings (GVWR) of 10,000 pounds or more to transport:
Non-hazardous commodities ($750,000).
Hazardous materials referenced in the FMCSA's insurance regulations at 49 CFR 1043.2(b)(2)(c) ($1,000,000).
Hazardous materials referenced in the FMCSA's insurance regulations at 49 CFR 1043.2(b)(2)(b) ($5,000,000).

I will operate only vehicles having Gross Vehicle Weight Ratings (GVWR) under 10,000 pounds to transport:
Any quantity of Class A or B explosives, any quantity of poison gas (Poison A), or highway route controlled quantity of radioactive materials ($5,000,000).
Commodities other than listed above ($300,000).

Safety Certification (Motor Carrier Applicants Only)

Applicants subject to Federal Motor Carrier Safety Regulation - If you will operate vehicles of more than 10,000 pounds GVWR and are, thus, subject to pertinent portions of the U.S. DOT's Federal Motor Carrier Safety Regulations 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 DOT regulations relating to the safe operation of commercial vehicles and the safe transportation of hazardous materials and it 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 the Federal Motor Carrier Safety Regulations;

(2) Can produce a copy of the Federal Motor Carrier Safety Regulations 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 Part 391);

(6) Has in place policies and procedures consistent with DOT regulations governing driving and operational safety of motor vehicles, including driver's hours of service and vehicle inspection, repair, and maintenance (49 CFR Parts 392, 395, and 396);

(7) Is familiar with and will have in place on the appropriate effective date, a system for complying with DOT regulations governing alcohol and controlled substances testing requirements (49 CFR 382 and 49 CFR Part 40).

Yes Initial here

Exempt Applicants - If you will operate only small vehicles (GVWR under 10,000 pounds) and will not transport hazardous materials, you are exempt from Federal Motor Carrier Safety Regulations, and must certify as follows: applicant is familiar with and will observe general operational safety guidelines, as well as any applicable state and local laws and requirements relating to the safe operation of commercial motor vehicles and the safe transportation of hazardous materials.

Yes Initial here

Affiliations with other former ICC, now FMCSA-Licensed Entities

Disclose any relationship you have or have had with any other FMCSA-regulated entity within the past 3 years. For example, this could be through a percentage of stock ownership, a loan, or management position. If this requirement applies to you, provide the name of the company, MC-number, DOT number, and that company's latest DOT safety rating.

Household Goods Certifications

Household Goods Motor Common Carrier Applicants must certify as follows: 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, 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.

Yes Initial here

Household Goods Motor Contract Carrier Applicants must certify as follows: 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, 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 U.S.C. 10101.

Yes Initial here

Household Goods Broker Applicants must certify as follows: 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 U.S.C. 10101.

Yes Initial here

Applicant's Oath

This oath applies to all supplemental filings to this application. I verify under penalty of perjury, under the laws of the United States of America, that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under 18 U.S.C. 1001 by imprisonment up to 5 years and fines up to $10,000 for each offense. Additionally, these misstatements are punishable as perjury under 18 U.S.C. 1621, which provides for fines up to $2,000 or imprisonment up to 5 years for each offense. I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or state offense involving the distribution or possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits, either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988 (21 U.S.C. 862). Finally, I certify that applicant is not domiciled in Mexico or owned or controlled by persons of that country.

Yes Initial here

Applicant's Agreement:

I hereby retain the services of DOTAuthority.com, Inc. (herein after referred to as "DOTAuthority"). I certify that I am authorizing DOTAuthority to serve as my representative and file my Application for Interstate Authority, USDOT Registration Application and Process Agent Registration on my behalf. I authorize DOTAuthority to make the above representations. I acknowledge that I remain responsible for compliance with all related federal and state laws and regulations, including, but not limited to insurance or bond requirements. I agree to hold DOTAuthority harmless with respect to any and all compliance related matters that may arise as a result of these filings.

Name: Date:

Thank you for ordering services from DOTAuthority.com, Inc.

Services may be paid for by money order, certified check, or credit card. Please do not mail cash or personal checks. If you would like to pay by credit card, please enter your credit card number and expiration date below. You may then print this page and either fax to us (866) 783-0169 or mail to 340 Vets Highway, Commack NY 11725.

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