| Owners Name: |
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| Owners SSN: |
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| Address of Owner: |
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| Owners City: |
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| State: |
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| Owners Zip Code: |
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| Owners Phone Number: |
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| Legal Business Name - If filing as a sole proprietor then list the name of the owner as Legal Business Name and list the business name in the DBA: |
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| DBA (Doing Business As): |
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| Business Address: |
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| Business City: |
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| State: |
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| Business Zip Code: |
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| Business County: |
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| Business Mailing Address if different than business address: |
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| Business Phone Number: |
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| Business Fax Number: |
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| Business Email address: |
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| Type of Business: |
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| IF you chose corporation then list which state papers were filed in: |
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| If partnership then list full name of all partners: |
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| Type of Authority needed: |
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| HAve you ever had a US DOT Number before?: |
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| If you answered yes to having a US DOT Number then list the number and the PIN number: |
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| Will you cross state lines?: |
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| Will you be For-Hire: |
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| What is your GVWR (Gross Vehicle Weight): |
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| Have you ever been convicted after Sept1,1989 of any Federal or State offenses involving the distribution of a controlled substance?: |
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| Number of straight trucks: |
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| Number of Trucks/Tractors: |
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| Number of trailers: |
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| Number of CDL Drivers: |
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| Number of drivers that will stay within state lines: |
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| Number of drivers that will cross state lines: |
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| Type of Freight hauled |
General Freight |
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Household goods |
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Metal, Sheets, Coils, Rolls |
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Motor Vehicles |
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Drive Away/ Tow Away |
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Logs, Poles, Beams, Lumber |
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Building Materials |
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Mobile Homes |
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Machinery, Large Objects |
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Fresh Produce |
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Liquids/ Gases |
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Intermodel Containers |
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Passengers |
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Oil Field Equipment |
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Livestock |
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Grain, Feed, Hay |
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Coal/ Coke |
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Meat |
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Garbage, Refuse, Trash |
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US Mail |
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Chemicals |
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Dry Bulk Commodities |
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Refrigerated Food |
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Beverages |
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Paper Products |
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Utility |
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Farm Supplies |
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Construction |
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Water Well |
| Other: |
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| Do you need a Kentucky KYU number: |
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| Do you need a New York Hut Permit: |
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| Do you need a New Mexico permit: |
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| The information that has been provided is true and accurate - please place name here: |
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| Fed ID/EIN #: |
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| Email Address: |
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