MCS-150C Intermodal Equipment Provider Identification Report

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 20 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

REASON FOR FILING

INTERMODAL EQUIPMENT PROVIDER IDENTIFICATION REPORT
(Application for U.S. DOT Number)

(Check Only One)

NEW APPLICATION

BIENNIAL UPDATE OR CHANGES

OUT OF BUSINESS NOTIFICATION

1. NAME OF INTERMODAL EQUIPMENT PROVIDER

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

3. PRINCIPAL STREET ADDRESS/ROUTE
NUMBER

5. MAILING ADDRESS (P O BOX)

7. STATE/PROVINCE

OMB NO: 2126-0013
Expiration Date:

8. ZIP CODE+4

13. PRINCIPAL BUSINESS PHONE NUMBER

4. CITY

9. COLONIA (MEXICO ONLY)

6. MAILING CITY

10. STATE/PROVINCE 11. ZIP CODE+4

14. PRINCIPAL CONTACT CELLULAR PHONE NUMBER

12. COLONIA (MEXICO ONLY)

15. PRINCIPAL BUSINESS FAX NUMBER

16. HAVE YOU EVER BEEN ISSUED A U.S. DOT NUMBER BY THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION?

Yes ______

No ______

If Yes, enter your U.S. DOT Number. ____________________________________________________________

17. DUN & BRADSTREET NO.

19. INTERNET E-MAIL ADDRESS

18. IRS/TAX ID NO.
EIN#

SSN#

20. NUMBER OF VEHICLES THAT CAN BE OPERATED IN THE U.S. (TRAILER CHASSIS ONLY)

OWNED

LEASED

SERVICED

21. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S), OFFICERS OR PARTNERS AND TITLES (e.g. PRESIDENT, TREASURER, GENERAL PARTNER, LIMITED PARTNER)

1. ____________________________________________________________
(Please print Name)

2. ___________________________________________________________
(Please print Name)

22. CERTIFICATION STATEMENT (to be completed by an authorized official)

I,

,
(Please print Name)

Signature ____________________________________________

Form MCS-150C (Rev. 12-12-2006)

certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or Federal Hazardous 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 ______________________________________________
(Please print)