MCS-150A Safety Certification for Application

OMB No: 2126-0013 Expiration Date:
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0013. Public reporting for this collection of information is estimated to be approximately 9 minutes per response, including
the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-MMI, Washington, D.C. 20590.

U.S. Department of Transportation
Federal Motor Carrier Safety Administration

Safety Certification for Application
(Safety Certification for Application for U.S. DOT Number)

1. NAME OF MOTOR CARRIER

2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME

3. PRINCIPAL STREET ADDRESS/ROUTE NUMBER

4. MAILING ADDRESS (P 0 BOX)

5. CITY

6. STATE/PROVINCE

7. ZIP CODE+4

11. PRINCIPAL PHONE NUMBER

13. USDOT NO.

14. MC OR MX NO.

8. MAILING CITY

9. STATE/PROVINCE

10. ZIP CODE+4

12. PRINCIPAL FAX NUMBER

15. DUN & BRADSTREET NO.

16. IRS/TAX ID NO.
EIN#
SSN#

17. INTERNET E-MAIL ADDRESS

18. SAFETY CERTIFICATIONS (Applicants subject to FMCSRs must complete certification item(s) 18A through 18C).
A.

B.

Applicant maintains current copies of all U.S. DOT Federal Motor Carrier Safety Regulations, Federal Motor Vehicle
Safety Standards, and the Hazardous Materials Regulations (if a property carrier transporting hazardous materials),
understands and will comply with such regulations, and has ensured that all company personnel are aware of the
current requirements.

Yes

No

Applicant certifies that the following tasks and measures will be fully accomplished and procedures fully implemented before it commences
operations in the United States.
1. Driver qualifications:
a)

b)

c)

d)

The carrier has in place a system and procedures for ensuring the continued qualification of drivers to
operate safely, including a safety record for each driver, procedures for verification of proper licensing of
each driver and procedures for identifying drivers who are not complying with the safety regulations.

Yes

No

The carrier has procedures in place to review drivers’ employment and driving histories for at least the last 3
years to determine whether or not the individual is qualified and competent to drive safely.

Yes

No

The carrier has established a program to review the records of each driver at least once every 12 months
and will maintain a record of the review.

Yes

No

The carrier will ensure that all of its drivers are at least 21 years of age and if applicable possess a valid
Commercial Drivers License (CDL).

Yes

No

Yes

No

Yes

No

2. Hours of Service:
a)

b)

3.

The carrier has in place a recordkeeping system and procedures to monitor the hours-of-service performed
by drivers, including procedures for continuing review of drivers’ log books, and for ensuring compliance
with all operations requirements.
The carrier has ensured that all drivers are knowledgeable of the hours-of-service requirements, and has
clearly and specifically instructed the drivers concerning the application to them of the 10-hour, 15-hour,
and 60 and 70-hour rules as well as the requirement for preparing daily log entries in their own handwriting
for each 24-hour period.

Drug and alcohol testing:
a)

The carrier is familiar with the alcohol and controlled substance testing requirements of 49 CFR part 382
and 49 CFR part 40 and has in place a program for systematic testing of drivers.

Yes

No

N/A

4. Vehicle condition:
a)

b)

The carrier has established a system and procedures for inspection, repair and maintenance of its vehicles
in a safe condition, and for preparation and maintenance of records of inspection, repair and maintenance
in accordance with the Federal Motor Carrier Safety Regulations and the Hazardous Materials Regulations.
The carrier will ensure that all violations and defects noted on inspection reports are corrected before
vehicles and drivers are permitted to continue operation.

5. Accident monitoring program:

Form MCS-150A (Rev. 06/2006)

Yes

No

Yes

No

a)

b)

6.

No

The carrier has established an accident countermeasures program and driver training program to reduce
accidents.

Yes

No

Yes

No

The carrier can and will produce records demonstrating compliance with the safety requirements within 48
hours of receipt of a request from a representative of the USDOT/FMCSA or other authorized Federal or
State official.

Hazardous Materials (to be completed by carriers of hazardous materials only).
a)

b)

c)

d)

e)

8.

Yes

Production of records:
a)

7.

The carrier has in place a program for monitoring vehicle accidents and maintains an accident register in
accordance with 49 CFR 390.15.

The HM carrier has full knowledge of the U.S. DOT Hazardous Materials Regulations and has established
programs for the thorough training of its personnel as required under 49 CFR part 172, Subpart H, and 49
CFR 177.816.

Yes

No

N/A

Yes

No

N/A

The HM carrier has established a system and procedures for filing and maintaining HM shipping
documents.

Yes

No

N/A

The HM carrier has a system in place to ensure that all HM trucks are marked and placarded as required by
49 CFR part 172, Subparts D and F.

Yes

No

N/A

The carrier will register under 49 CFR part 107, Subpart G, if transporting any quantity of hazardous
materials requiring the vehicle to be placarded.

Yes

No

N/A

Yes

No

N/A

The carrier has established a system and procedures for inspection, repair and maintenance of its reusable
hazardous materials packages (cargo tanks, portable tanks, cylinders, intermediate bulk containers, etc.) in
a safe condition, and for preparation and maintenance of records of inspection, repair and maintenance in
accordance with the U.S. DOT Hazardous Materials Regulations.

For Cargo Tank (CT) Carriers of HM
a)

The carrier has a system in place to ensure that its cargo tanks are inspected and tested as required by 49
CFR 180 by a facility registered with the U.S. DOT under part 107, Subpart F.

By signing these certifications, the carrier official is on notice that the representations made herein are subject to verification through inspections in the
United States and through the request for and examination of records and documents. Failure to support the representations contained in this application
could form the basis of a proceeding to assess civil penalties and/or lead to the revocation of the authority granted.
C.

All applicants must certify as follows:
1. Applicant is willing and able to provide the proposed operations or service and to comply with all pertinent
statutory and regulatory requirements and regulations issued or administered by the U.S. Department of
Transportation, including operational regulations, safety fitness requirements, motor vehicle safety standards,
and minimum financial responsibility requirements.
2. Applicant is willing and able to produce for review or inspection documents which are requested for the purpose
of determining compliance with applicable statutes and regulations administered by the U.S. Department of
Transportation, including the Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety Standards
and Hazardous Materials Regulations, within 48 hours of any written request.
3. Applicant is not presently disqualified from operating commercial vehicles in the United States pursuant to the
Motor Carrier Improvement Act of 1999 or any other law.

Yes

No

Yes

No

Yes

No

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 requirements 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.

19. Certification Statement (to be completed by an authorized official)
I, _________________________________________________ , certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or the Federal Hazardous
(Please print Name)

Signature ____________________________________
Form MCS-150A (Rev. 06/2006)

Materials Regulations. Under penalties of perjury, I declare that the information entered on this report is, to
the best of my knowledge and belief, true, correct, and complete.
Date _________________________________ Title ____________________________________________