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pdfUNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
For FMCSA Use Only
Date Received: ___________________
USDOT Number: ___________________
□Inactive ___________________
□Active ____________________
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-XXXX. Public reporting for this collection of information is estimated to be approximately 1 hour, 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, and will be
provided confidentiality to the extent allowed by law. 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-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
FMCSA REGISTRATION / UPDATE(S)
(APPLICATION FOR USDOT NUMBER/OPERATING AUTHORITY)
FORM MCSA-1
PLEASE READ THE INSTRUCTIONS FOR THIS FORM CAREFULLY
BEFORE PROCEEDING
There are six reasons to file this form: New Registration, Reinstatement, New Entrant Reapplication, Biennial Update, Name / Address / Form
of Business Change(s), or Other Update(s). For each reason please complete the appropriate sections of this form as indicated below. Form
MCSA-1, attachments, and statements must be completed in English.
PLEASE COMPLETE ALL
APPLICABLE SECTIONS
TYPE OF OPERATION
MOTOR CARRIER (NOT DOMICILED IN
MEXICO) OF:
HOUSEHOLD GOODS
HAZARDOUS MATERIALS
PROPERTY
CARRIER/SHIPPER
PASSENGERS
MOTOR CARRIER (DOMICILED IN
MEXICO) OF:
HOUSEHOLD GOODS
HAZARDOUS MATERIALS
PROPERTY
CARRIER/SHIPPER
PASSENGERS
MOTOR CARRIER (NOT DOMICILED IN NORTH
AMERICA) OF:
HOUSEHOLD GOODS
HAZARDOUS MATERIALS CARRIER/SHIPPER
PROPERTY
PASSENGERS
BROKER OF:
HOUSEHOLD GOODS
PROPERTY
FREIGHT FORWARDER (WITH VEHICLES) OF:
HOUSEHOLD GOODS
PROPERTY
FREIGHT FORWARDER, (NO VEHICLES) OF:
HOUSEHOLD GOODS
PROPERTY
INTERMODAL EQUIPMENT PROVIDERS
CARGO TANK FACILITY
MCSA-1 (as of 10-2011)
1-2
NEW REGISTRATION(1),
NEW ENTRANT REAPPLICATION (2)
3-5
6
REINSTATEMENT
(Sections and attachments (ATT)
to be Completed)
BIENNIAL UPDATE (3),
NAME / ADDRESS /
FORM OF BUSINESS
CHANGE(S) (4), OTHER
UPDATE(S) (5)
(Sections to be Completed
A,B,F,K,M,N,O
A,B,C,D,K,M,N,O
A,B,K,M,N,O
A,B,G,H,K,M,N,O
A,B,F,K,N
A,B,C,D,K,N
A,B,K,N
A,B,G,H,K,N
A,B,F,J,K,M,N,O
A,B,C,D,K,M,N,O
A,B,K,M,N,O
A,B,G,H,K,M,N,O
A,B,F,I,K,L,M,N,O
A,B,C,D,I,K,L,M,N,O
A,B,I,K,L,M,N,O
A,B,G,H,I,K,L,M,N,O
A,B,F,I,K,N
A,B,C,D,I,K,N
A,B,I,K,N
A,B,G,H,I,K,N
A,B,F,I,K,L,M,N,O
A,B,C,D,I,K,L,M,N,O
A,B,I,K,L,M,N,O
A,B,G,H,I,K,L,M,N,O
A,B,F,J,K,L,M,N,O
A,B,C,D,J,K,L,M,N,O
A,B,J,K,L,M,N,O
A,B,G,H,J,K,L,M,N,O
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A,B,G,H,J,K,N
A,B,F,J,K,L,M,N,O
A,B,C,D,J,K,L,M,N,O
A,B,J,K,L,M,N,O
A,B,G,H,J,K,L,M,N,O
A,B,F,K,M,N,O
A,B,K,M,N,O
A,B,F,K,N
A,B,K,N
A,B,F,K,M,N,O
A,K,M,N,O
A,B,F,K,M,N,O
A,B,K,M,N,O
A,B,F,K,N
A,B,K,N
A,B,F,K,M,N,O
A,B,K,M,N,O
A,K,M,N,O
A,K,M,N,O
A,B,M,N,O
A,E,M,N,O
A,K,N
A,K,N
A,B,N
A,E,N
A,K,M,N,O
A,K,M,N,O
A,B,M,N,O
A,E,M,N,O
Page 1 of 30
(Sections to be Completed)
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
REASONS FOR FILING (Check only one)
□NEW REGISTRATION
□NEW ENTRANT REAPPLICATION
□REINSTATEMENT
□BIENNIAL UPDATE
□NAME / ADDRESS / FORM OF BUSINESS CHANGE(S)
□OTHER UPDATE(S)
SECTION A.
BUSINESS DESCRIPTION
FEES
$300
$300
$10
No fee
No fee
No fee
(TO BE COMPLETED BY ALL)
1. LEGAL BUSINESS NAME
2. DOING BUSINESS AS NAME (if different from Legal Business Name)
3. BUSINESS ADDRESS/PRINCIPAL PLACE OF BUSINESS
__________________________________________ ___________________
STREET ADDRESS /ROUTE NUMBER
___________________
CITY
STATE/PROVINCE
__________
ZIP CODE+4
__________________
COLONIA (Mexico Only)
________________
FOREIGN COUNTRY
4. MAILING ADDRESS (Must include the physical street name and number; P.O. Box Numbers are not accepted.)
_________________________________________ ___________________
STREET ADDRESS
CITY
___________________
STATE/PROVINCE/
__________
ZIP CODE+4
__________________
COLONIA (Mexico Only)
________________
FOREIGN COUNTRY
5. COUNTRY OF DOMICILE OF PRINCIPAL PLACE OF BUSINESS
□United States
□Canada
□Mexico
____________________
______________________
Canadian NSC Number
(National Safety Code)
□Other Country
Mexico RFC Number
(Federal Taxpayer Registry)
6. PRINCIPAL BUSINESS TELEPHONE NUMBER
7. PRINCIPAL BUSINESS FAX NUMBER
8. PRINCIPAL BUSINESS CELL PHONE NUMBER
9. USDOT NUMBER (if updating)
10. MC, MX AND FF NUMBER(S) (if updating)
MOTOR CARRIER
(MC)
MEXICO
DOMICILED
CARRIER (MX)
FREIGHT
FORWARDER (FF)
11. *IRS TAX ID NUMBER (See instructions)
EIN NUMBER
OR
SSN NUMBER
12. DUN & BRADSTREET NUMBER (if applicable)
MCSA-1 (as of 10-2011)
Page 2 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
13. FORM OF BUSINESS (Select all that apply)
□ Sole Proprietor
□Partnership
□ Unit of State or Local Government
□ Limited Liability Company
□Corporation
State of Incorporation ________________________
14. OWNERSHIP and CONTROL
□Owned/controlled by citizen of U.S.
□Owned/controlled by citizen of Canada
□Owned/controlled by citizen of Mexico
□Owned/controlled by citizen of other foreign country
____________________________________________
Name of Country
15. NAME(S) OF SOLE PROPRIETOR, PARTNERS, OR OFFICERS AND TITLES, (e.g. PRESIDENT, TREASURER,
GENERAL PARTNER, LIMITED PARTNER)
NAME ___________________________________________
TITLE _________________________________________
NAME ___________________________________________
TITLE _________________________________________
NAME ___________________________________________
TITLE _________________________________________
16. REVENUE: Enter your gross annual operating revenue for the last calendar year
Year:
MCSA-1 (as of 10-2011)
□□□□
Revenue (U.S. Dollars): $ ____________________
Page 3 of 30
Number of months if partial year ________
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
17. OPERATION CLASSIFICATION (Check all items that apply)
c. Property Broker
a. For-Hire Motor Carrier
□General Freight (except Household Goods)
□Household Goods
□ Property
□Hazardous Materials
□Household Goods
□ Exempt Commodities
□ Other Non-Hazardous Freight
d. Freight Forwarder
□General Freight (except Household Goods)
□Household Goods
□Passengers
□Charter & Special Operations
□Regular Route
□Limousine/Van Operations
□FTA Grantee
e.
f.
g.
h.
□Government Entity
□ Cargo Tank Facility
□ Intermodal Equipment Provider
□ Other____________________________________
□Mexico-owned, U.S.-based Enterprise
□United States-based Enterprise Owned or Controlled by Persons of
Mexico Providing Truck Services for the Transportation of International
Cargo (except Household Goods)
□United States-based Enterprise Owned or Controlled by Persons of
Mexico Providing Truck Services for the Transportation of International
Household Goods Shipments
□Charter & Special Operations (passengers) – Mexico-owned, U.S.-based
Enterprise
□Regular Route (passengers) – Mexico-owned, U.S.-based Enterprise
b. Private Motor Carrier
□Property – Hazardous Materials
□Property – Non-Hazardous Freight
□Passengers - Business
□Passengers - Non-business
□Migrant Workers
18. COMPANY CONTACT PERSON (Please designate an individual within your company to respond to inquiries)
_____________________________________________________________________________________________________________
Name, title, and position
_____________________________________________________________________________________________________________
Street Address
____________________________________________________
City
(______) _________________________
Telephone Number
MCSA-1 (as of 10-2011)
______________________
State/Province
(______) ____________________________
Fax Number (optional)
___________________________
Country
___________________
Zip Code/Postal Code
(______) _________________________
Cell Phone (optional )
Page 4 of 30
_______________________________
Colonia – Mexico only
________________________________________________
Internet E-mail Address (optional)
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
19. APPLICANT’S REPRESENTATIVE (Please designate an individual to respond to inquiries, if applicable)
_____________________________________________________________________________________________________________
Name and title, position, and relationship to applicant
_____________________________________________________________________________________________________________
Street Address
___________________________________________________
City
(______) _________________________
Telephone Number
______________________
State/Province
(______) ____________________________
Fax Number (optional)
___________________________
Country
___________________
Zip Code/Postal Code
(______) _________________________
Cell Phone (optional)
_______________________________
Colonia – Mexico only
________________________________________________
Internet E-mail Address (optional)
20. CERTIFICATION STATEMENT (to be completed by the applicant )
I,
(Please Print Name)
, certify that I am familiar with the Federal Motor Carrier Safety Regulations and, if applicable, the Federal
Hazardous Materials Regulations, and the Federal Motor Carrier Commercial Regulations. Under penalties of perjury, under the laws of the United States of America, I
certify that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualifed 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 $250,000 for each offense. Additionally, these statements are punishable as perjury under 18 U.S.C. § 1621, which provides for fines up to $250,000 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, formerly Pub. L. 100-690, Title V, Section 5301, Nov. 18, 1988, 102 Stat.4310,
renumbered and amended Pub. L. 101-647, Title X, Section 1002(d), Nov. 29, 1990, 104 Stat. 4827) (21 U.S.C. § 826).
Signature ______________________________________________
MCSA-1 (as of 10-2011)
Date ____________________
Page 5 of 30
Title ________________________________________________
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION B.
OMB Control No.: 2126-xxxx
Expires:
OPERATION CLASSIFICATION
(TO BE COMPLETED BY ALL MOTOR CARRIERS,
FREIGHT FORWARDERS WITH VEHICLES AND INTERMODAL EQUIPMENT PROVIDERS)
21. TYPE OF OPERATION Please check all that apply: (HM= Hazardous Materials)
□INTERSTATE (NON-HM)
□INTERSTATE (HM)
□INTRASTATE (NON-HM)
□INTRASTATE (HM)
22. CARGO Please check all classifications of cargo that applicant transports or handles:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
General Freight
p.
Household Goods
q.
Metal: Sheets, Coils, Rolls
r.
Motor Vehicles
s.
Driveaway-Towaway
t.
Logs, Poles, Beams, Lumber
u.
Building Materials
v.
Mobile Homes
w.
Machinery, Large Objects
x.
Fresh Produce
y.
Liquid/Gases
z.
Intermodal Containers
aa.
Passengers
bb.
Oil Field Equipment
cc.
Livestock
dd.
23. MILEAGE (to the nearest 10,000 miles for last calendar year)
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Grain, Feed, Hay
Coal/Coke
Meat
Garbage, Refuse, Trash
U.S. Mail
Chemicals
Commodities (Dry), in Bulk
Refrigerated Food
Beverages
Paper Products
Utility Service
Farm Supplies
Construction
Water Well
Other (Please specify): ___________________________________
Please estimate the total number of miles your commercial motor vehicle(s) (leased or owned) traveled in the U.S. during the last calendar year.
Calendar Year:
□□□□
Mileage: ____________________________
24. (a) NUMBER OF VEHICLES WITH A GROSS VEHICLE WEIGHT RATING (GVWR), GROSS COMBINATION
WEIGHT RATING (GCWR), GROSS VEHICLE WEIGHT (GVW) OR GROSS COMBINATION WEIGHT (GCW) ≥ 10,001
POUNDS THAT WILL BE OPERATING IN THE U.S.
Straight
Truck(s)
Truck
Tractor(s)
Trailer
(s)
IEP
Trailer
Chassis
only
Hazmat
Cargo
Tank
Truck(s)
Hazmat
Cargo
Tank
Trailer(s)
Minibus(es)
School Bus(es)
Motor
Coaches
Van(s)
Limousine
Number of vehicles carrying number of passengers (including the driver) below
1-8
9-15
16+
16+
1-8
9-15
1-8
9-15
16+
Owned
Term
Leased
Trip
Leased
Serviced
(b) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW OR GCW ≥ 10,001 POUNDS THAT WILL BE OPERATING
IN CANADA OR MEXICO. (To be completed by US-domiciled motor carriers only)
CANADA
MEXICO
(c) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW OR GCW ≥ 10,001 POUNDS THAT OPERATE INTERSTATE.
MCSA-1 (as of 10-2011)
Page 6 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
25. (a) NUMBER OF DRIVERS THAT WILL BE OPERATING IN THE U.S.
INTERSTATE
INTRASTATE
TOTAL DRIVERS
TOTAL COMMERCIAL
DRIVER’S LICENSE(CDL)
DRIVERS
Within 100 air-mile Radius
Beyond 100 air- mile Radius
(b) NUMBER OF DRIVERS THAT WILL BE OPERATING IN CANADA OR MEXICO. (To be completed by US-domiciled
motor carriers only)
CANADA
MCSA-1 (as of 10-2011)
MEXICO
Page 7 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION C. HAZARDOUS MATERIALS (HM)
(TO BE COMPLETED BY HM MOTOR CARRIERS/SHIPPERS)
26. HAZARDOUS MATERIALS CARRIED (Please circle all that apply)
C (Carried) S (Shipped) B (Bulk) – >119 gallons for liquids, 882 pounds (lbs) for solids, 1,000 lbs. water capacity for
gases in a single package NB (Non-Bulk) – <119 gallons
C
S
A.
Div 1.1 Explosives (with mass explosion hazard)
B
NB
C
S
V.
Div 4.3 Dangerous when wet material
B
NB
C
S
B.
Div 1.2 Explosives (with projection hazard)
B
NB
C
S
W.
Div 5.1 Oxidizer
B
NB
B
NB
C
S
X.
Div 5.2 Organic Peroxide
B
NB
B
NB
C
S
Y.
Div 6.2 Infectious substance (Etiologic agent)
B
NB
B
NB
C
S
Z.
B
NB
B
NB
C
S
AA.
B
NB
C
S
C.
Div 1.3 Explosives (with predominantly fire
hazard)
C
S
D.
Div 1.4 Explosives (with no significant blast
hazard)
C
S
E.
C
S
F.
C
S
G.
Div 2.1 Flammable gas
B
NB
C
S
BB.
Div 6.1 Poison (Poisonous liquid with no
inhalation hazard)
B
NB
C
S
H.
Div 2.1 Liquefied Petroleum Gas (LPG)
B
NB
C
S
CC.
Div 6.1 Solid (Meets the definition of a
poisonous solid)
B
NB
C
S
I.
Div 2.1 Methane Gas
B
NB
C
S
DD.
Class 7 Radioactive materials.
B
NB
C
S
J.
Div 2.2 Non-flammable compressed gas
B
NB
C
S
EE.
Highway Route Controlled Quantity of
Radioactive Material (HRCQ)
B
NB
C
S
K.
Div 2.2 (Anhydrous Ammonia)
B
NB
C
S
FF.
Class 8 Corrosive material
B
NB
C
S
L.
Div 2.3 A (Poison Gas which is Poison Inhalation
Hazard (PIH) Zone A
B
NB
C
S
GG
Class 8 A (Corrosive liquid which is a PIH
Zone A)
B
NB
C
S
M.
Div 2.3 B (Poison Gas which in PIH Zone B)
B
NB
C
S
HH.
Class 8 B (Corrosive liquid which is a PIH Zone
B)
B
NB
C
S
N.
DIV 2.3 C (Poison Gas which is PIH Zone C)
B
NB
C
S
II.
Class 9 Miscellaneous hazardous material
B
NB
C
S
O.
DIV 2.3 D (Poison Gas which is PIH Zone D)
B
NB
C
S
JJ.
Elevated Temperature Material (Meets
definition in 49 CFR § 171.8 for an elevated
temperature material)
B
NB
C
S
P.
Class 3 Flammable and combustible liquid
B
NB
C
S
KK.
Infectious Waste (Meets definition in 49 CFR
171.8 for an infectious waste)
B
NB
C
S
Q.
Class 3 A (Flammable liquid which is a PIH Zone
A)
B
NB
C
S
LL.
Marine Pollutants (Meets Definition in 49 CFR
§ 171.8 for a marine pollutant)
B
NB
C
S
R.
Class 3 B (Flammable liquid which is a PIH Zone
B)
B
NB
C
S
MM.
Hazardous Substances (RQ) (Meets definition
in 49 CFR § 171.8 of a reportable quantity of a
hazardous substance)
B
NB
C
S
S.
Combustible Liquid (Refer to 49 CFR § 173.20
(b))
B
NB
C
S
NN.
Hazardous Waste (Meets definition in 49 CFR
§ 171.8 of a hazardous waste)
B
NB
C
S
T.
Div 4.1 Flammable Solid
B
NB
C
S
OO.
ORM (Meets definition in 49 CFR § 171.8 of
Other Regulated Material)
B
NB
C
S
U.
Div 4.2 Spontaneously combustible material
B
NB
Div 1.5 Very insensitive explosives; blasting
agents
Div 1.6 Extremely insensitive detonating
substances
MCSA-1 (as of 10-2011)
Page 8 of 30
Div 6.1 A (Poison Liquid which is a PIH Zone
A)
Div 6.1 B (Poison Liquid which is a PIH Zone
B)
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION D.
OMB Control No.: 2126-xxxx
Expires:
HAZARDOUS MATERIALS PERMITTING (TO BE COMPLETED BY HM MOTOR CARRIERS)
27. WHICH OF THE FOLLOWING HAZARDOUS MATERIAL(S) DOES YOUR COMPANY TRANSPORT? CHECK ALL THAT APPLY:
Highway Route Controlled Quantities (HRCQ) of Radioactive materials.
More than 25 kg (55 pounds) of a Division 1.1, 1.2, or 1.3 material or a quantity of Division 1.5 material that requires placarding.
For materials that meet the definition of “material poisonous by inhalation” (TIH) as defined in 49 CFR 171.8: More than 1 liter (L)(1.08 quarts) per
package of a material meeting the definition of a Hazard Zone A TIH material, a material meeting the definition of a Hazard Zone B TIH material in a
bulk package (capacity greater than 450 liters [119 gallons]), or a material meeting the definition of a Hazard Zone C or D TIH material in a bulk
packaging that has a capacity greater than 13,248 L (3,500 gallons).
Shipments of compressed or refrigerated liquid methane or liquefied natural gas with a methane content of at least 85% in a bulk packaging that has a
capacity greater than 13,248 L (3,500 gallons)
28. IF YOU CHECKED QUESTION 27, ARE YOU APPLYING FOR OR RENEWING A HAZARDOUS
MATERIAL (HM) SAFETY PERMIT? PLEASE CHECK ONE:
Initial
Renewal
30. DOES YOUR COMPANY CERTIFY IT HAS A SATISFACTORY SECURITY PROGRAM IN PLACE AS
REQUIRED IN 49 CFR PART 385, SUBPART E?
Yes
No
31. IS YOUR COMPANY REQUIRED BY ANY STATE(S) TO HAVE A PERMIT FOR ANY OF THE
HAZARDOUS MATERIALS LISTED IN QUESTION 27?
Yes
No
29. IF YOUR COMPANY DOES NOT HAVE A U.S. DOT NUMBER, HOW MANY ACCIDENTS AS DEFINED
IN 49 CFR 390.5 HAS YOUR COMPANY HAD IN THE PAST 12 MONTHS?
32. IF YOUR ANSWER TO QUESTION 31 IS YES, CHECK THE STATE(S) IN WHICH YOU HAVE THE PERMIT.
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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.
MCSA-1 (as of 10-2011)
Page 9 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
33. CERTIFICATION STATEMENT (TO BE COMPLETED BY AN AUTHORIZED OFFICIAL)
I, ____________________________________, certify that I am familiar with the 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.
Signature ____________________________________ Date _________________________________ Title ____________________________________________
MCSA-1 (as of 10-2011)
Page 10 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION E.
OMB Control No.: 2126-xxxx
Expires:
CARGO TANK FACILITY (TO BE COMPLETED BY AN APPLICANT REGISTERING CARGO TANK
FACILITIES UNDER 49 CFR PART 107, SUBPART F)
34. Please refer to instructions for Section E to complete the following information for each cargo tank facility being registered.
Functions
Exemptions/Special
permits
External Visual Inspection
Internal Visual Inspection
Leakage Test
Lining Inspection
Thickness Test
Pressure Test
Manufacture
Assembly
Repair (Non-ASME)
Repair (ASME)
Certification (Design
Certified Engineer)
Component Manufacture
Where do you use testing/
inspection equipment?
Name:
Street:
City:
State:
Title:
First Name:
Phone:
Email:
MCSA-1 (as of 10-2011)
Vehicles
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC306
MC307
MC312
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
MC330
MC331
MC338
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC310
MC311
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC300
MC301
MC302
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC303
MC304
MC305
MC310
MC311
MC310
MC311
MC310
MC311
MC310
MC311
MC310
MC311
MC310
MC311
MC310
MC311
MC310
MC311
Mobile Testing Information
None
Fixed Facility
Mobile
Processing Agent
(To be completed if the registrant is not a resident of the United States)
Zip/Postal Code
Responsible Person (Facility Location)
Position:
Last Name:
Fax:
Page 11 of 30
Both
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
Design Certified Engineers/Registered Inspectors
Name:
Street:
Type:
Type:
Cargo Tank #
Stamp Type
Non-Employee Design Certified Engineers/Registered Inspectors
Type
Certification #
Stamp
Authorization Date
Company
Expiration Date
I certify that all Registered Inspectors and Design Certifying Engineers used in performance of the
prescribed functions meet the minimum qualification requirements set forth in 49 CFR 171.8, that I am the
person responsible for ensuring compliance with the applicable requirements of this chapter, and that I
have knowledge of the requirements applicable to the functions to be performed.
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.
Yes
No
Certifying Name:
Certifying Title:
Certifying Email:
SECTION F.
TRANSPORTATION OF HOUSEHOLD GOODS
(TO BE COMPLETED BY HOUSEHOLD
GOODS MOTOR CARRIERS, HOUSEHOLD GOODS BROKERS, AND HOUSEHOLD GOODS FREIGHT
FORWARDERS)
35. CERTIFICATION: ARBITRATION PROGRAM AND TARIFF
MOTOR CARRIER OF HOUSEHOLD GOODS (including United States-based enterprises transporting international household goods shipments)
I, _________________________________________________________________________________, certify that I am fit, willing, and able to provide the specialized
Print First and Last Name and Title
services necessary to transport household goods. I am familiar with FMCSA regulations for household goods movements, have acquired or am willing to acquire the
protective equipment and trained operators necessary to perform household goods movements. I certify that my tariff is available for inspection by shippers upon reasonable
request. I further certify that I will offer arbitration as a means of settling loss and damage disputes and disputes regarding carrier charges in addition to those collected at
delivery. The following information can be used to contact a representative of the arbitration program in which I will participate.
Contact information for the arbitration program in which I will participate:
Name
Address
_____________________________________________________________________
Signature of Motor Carrier Representative
MCSA-1 (as of 10-2011)
Page 12 of 30
Telephone Number
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
BROKER OF HOUSEHOLD GOODS
I, ___________________________________________________________________________________, certify that applicant is fit, willing, and able to provide household
Print Name and Title
goods brokerage operations and to comply with all pertinent statutory and regulatory requirements.
____________________________________________________________
____________________________
Signature of Company Official
Date
__________________________________
Title
FREIGHT FORWARDER OF HOUSEHOLD GOODS
I, ___________________________________________________________________________________, certify that applicant is fit, willing, and able to provide household
Print Name and Title
goods freight-forwarding operations and to comply with all pertinent statutory and regulatory requirements.
____________________________________________________________
Signature of Company Official
____________________________
Date
__________________________________
Title
HOUSEHOLD GOODS MOTOR CARRIER APPLICANTS MUST :
1. Provide evidence of participation in an arbitration program and a copy of the notice they provide to shippers of the availability of binding arbitration.
2. Identify their tariff and provide a copy of the notice to shippers of the availability of that tariff for inspection, indicating how that notice is provided.
3. Disclose the following:
(a) Do you currently have, or have you had within the last 3 years of the date of filing this application, relationships involving common stock, common ownership, common
management, or common familial relationships with any other motor carrier, freight forwarder, or broker of household goods?
YES
NO
(b) If yes, please provide the following information for all applicable relationships in 3(a ) above (supplemental documents should be scanned and uploaded along with this
application)::
•
Description of affiliate or relationship
•
Name of the company
•
MC/FF Number
•
USDOT Number
•
Latest DOT safety rating
Applicant certifies that it has access to, has read, is familiar with, and will observe all applicable Federal laws relating to consumer protection, estimating, consumers’ rights
and responsibilities, and options for liability for loss and damage.
____________________________________________________________
Signature of Company Official
MCSA-1 (as of 10-2011)
____________________________
Date
Page 13 of 30
__________________________________
Title
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION G. TRANSPORTATION OF PASSENGERS (TO BE COMPLETED BY PASSENGER CARRIERS)
36. GOVERNMENT FUNDING STATUS - SPECIFY THE NATURE OF GOVERNMENTAL FINANCIAL ASSISTANCE YOU
RECEIVE, IF ANY, BY CHECKING THE APPROPRIATE BOX BELOW (Check only one box)
□Public recipient - Applicant is any of the following: any State; any municipality or other political subdivision of a State; any public agency or instrumentality of such
entities of one or more State(s); an Indian tribe; and any corporation, board or other person owned or controlled by such entities or owned by, controlled by, or under
common control with such a corporation, board, or person which is receiving or has ever received governmental financial assistance for the purchase or operation of
any bus.
□Private recipient – Applicant is not a public recipient but is receiving, or has received in the past, governmental financial assistance in the form of a subsidy for the
purchase, lease or operation of any bus.
□Non-recipient – Applicant is not receiving, or using equipment acquired with, governmental financial assistance.
Public Interest Criteria: Regular route public and private recipient applicants may introduce supplemental evidence describing how the
proposed service will respond to existing transportation needs or is otherwise consistent with the public interest. Filing this evidence with
the application is optional, but it may be needed later, if the application is protested.
Public Recipient Applicants: All public recipient applicants for charter or special transportation must submit evidence to demonstrate either
that:
(1) No motor carrier of passengers (other than a motor carrier of passengers that is a public recipient of governmental assistance) is
providing, or is willing and able to provide, the transportation to be authorized by the certificate; or
(2) The transportation to be authorized by the certificate is to be provided entirely in the area in which the public recipient provides
regularly scheduled mass transportation services.
Supplemental evidence should be scanned and uploaded along with your application.
Fitness Only Criteria: No additional evidence is needed from non-recipient applicants for charter and special transportation.
37. PASSENGER CARRIER COMPLIANCE CERTIFICATION
I, ___________________________________________________________________________________, certify that I am fit, willing, and able to comply with all pertinent
Print Name and Title
statutory and regulatory requirements including the U.S. Department of Transportation’s Americans with Disabilities Act regulations for over-the-road bus companies located
at 49 CFR Part 37, Subpart H, if applicable.
____________________________________________________________
Signature of Company Official
____________________________
Date
__________________________________
Title
Private entities that are primarily in the business of transporting people, whose operations affect commerce, and that transport passengers in an over-theroad bus (defined as a bus characterized by an elevated passenger deck over a baggage compartment) are subject to the U.S. Department of Transportation’s
Americans with Disabilities Act regulations, located at 49 CFR Part 37, Subpart H. Charter and special transportation corresponds to demand responsive
service and service over regular routes corresponds to fixed route service under the Americans with Disabilities Act regulations for over-the-road bus
companies located at 49 CFR Part 37, Subpart H. For a general overview of these regulations, please refer to the Federal Motor Carrier Safety
Administration’s website at www.fmcsa.dot.gov.
MCSA-1 (as of 10-2011)
Page 14 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION H. SCOPE OF AUTHORITY (TO BE COMPLETED BY PASSENGER CARRIERS)
38.
(1) □ Charter and special transportation, in interstate or foreign commerce, between points in the United States.
(2) □ Charter and special transportation, in interstate or foreign commerce, between points in the United States, provided by United States-based
enterprises owned or controlled by persons of Mexico.
(3) □ Service as a passenger carrier over regular routes. (Regular route passenger carrier authority to perform regularly scheduled service.) Regular
route passenger service includes authority to transport newspapers, baggage of passengers, express packages, and mail in the same motor
vehicle with passengers, or baggage of passengers in a separate motor vehicle. Public recipient applicants requesting authority to operate over
regular routes should scan and upload to the application a description of the specific routes over which you intend to provide regularly
scheduled service. You must also furnish a map clearly identifying each regular route involved in your passenger carrier service description(s).
(4) □ Service as a passenger carrier over regular routes provided by United States-based enterprises owned or controlled by persons of Mexico.
Regular route passenger service includes authority to transport newspapers, baggage of passengers, express packages, and mail in the same
motor vehicle with passengers, or baggage of passengers in a separate motor vehicle.
(5) □ Intrastate regular route authority
Are you also requesting intrastate authority to provide the service described in item 3 or 4?
YES NO
NOTE: The FMCSA has no jurisdiction to grant intrastate authority independently of interstate regular route authority. No carrier may
conduct operations under a certificate authorizing intrastate regular route service unless it actually is conducting substantial operations in
interstate commerce over the same route(s).
MCSA-1 (as of 10-2011)
Page 15 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION I. COMMERCIAL ZONE OPERATIONS (TO BE COMPLETED BY MEXICO-DOMICILED
MOTOR CARRIERS OPERATING EXCLUSIVELY WITHIN COMMERCIAL ZONES )
“Within Commercial Zones” refers to service between Mexico and the United States entirely within the commercial zone of a municipality that is adjacent to Mexico. A
Mexico-domiciled motor carrier may not provide point-to-point transportation services, including express delivery services, within the United States for goods other than
international cargo.
39. SCOPE OF REGISTRATION
□Service as a for-hire motor carrier of property (except household goods) within the commercial zones
□Service as a for-hire motor carrier of household goods within the commercial zones
□Service as a private motor carrier of property (handling applicant’s own goods) within the commercial zones
□Service as a passenger motor carrier within the commercial zones
40. UNITED STATES ADDRESS: (a) Do you currently maintain an office in the United States?
YES
NO
(b) If yes, please provide the full street address, telephone number, and fax number.
_______________________________________________________________________________________________
Street Address
___________________________________________________________________________
City
(______________) _________________________
(Telephone Number)
_______________________
State
_______________________
Country
____________________
Zip Code
(______________) ____________________________
(Fax Number)
SECTION J. NON-NORTH AMERICA-DOMICILED CARRIERS (TO BE COMPLETED BY MOTOR
CARRIERS NOT DOMICILED IN THE UNITED STATES, MEXICO OR CANADA)
“Non-North America-domiciled” refers to an applicant whose principal place of business is located outside of the United States, Mexico, or Canada and is seeking to
provide the following transportation service in foreign commerce:
41. SCOPE OF REGISTRATION
□Transportation of property by a Non-North America-domiciled motor carrier between points outside of the United States and all points in the United States.
□Transportation of passengers by a non-North America-domiciled passenger carrier providing charter and tour bus operations between points outside of the United
States and points in the United States.
□Transportation of passengers by a non-North America-domiciled private motor carrier of passengers between points outside of the United States and points in the
United States.
42. Indicate the principal border crossing points that applicant intends to utilize.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
MCSA-1 (as of 10-2011)
Page 16 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
43. UNITED STATES ADDRESS: (a) Do you currently maintain an office in the United States?
YES
NO
(b) If yes, please provide the full street address, telephone number, and fax number.
_____________________________________________________________________________________________________________
Street Address
____________________________________________________________________________
City
(______) _________________________
(Telephone Number)
MCSA-1 (as of 10-2011)
_______________________
State
_______________________
Country
(______) ____________________________
(Fax Number)
Page 17 of 30
____________________
Zip Code
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION K.
OMB Control No.: 2126-xxxx
Expires:
ADDITIONAL INFORMATION (TO BE COMPLETED BY FOR-HIRE MOTOR CARRIERS AND
PRIVATE HAZARDOUS MATERIALS CARRIERS, INCLUDING THOSE DOMICILED IN MEXICO AND
OUTSIDE OF-NORTH AMERICA, AND BY BROKERS AND FREIGHT FORWARDERS)
44. FINANCIAL RESPONSIBILITY
(Check all boxes that apply)
If applicant is a Mexico-domiciled motor carrier of property and operates exclusively within the U.S.-Mexico border commercial zones, please skip to item 44f, under this
section.
a. MOTOR PASSENGER CARRIER
For-Hire motor passenger carriers operating in the United States, including Mexico-domiciled motor passenger carriers, must maintain public liability insurance. The
minimum amount of coverage is shown in parentheses.
(Please check only one): Applicant
□Has one or more vehicles with a seating capacity of 16 passengers or more, including the driver ($5,000,000 U.S.)
□Has only motor vehicles with a seating capacity of 15 passengers or fewer, including the driver ($1,500,000 U.S.)
□Receives a grant from the Federal Transit Administration (FTA) under 49 U.S.C. §§ 5307, 5310, or 5311. Applicant understands that it is not required to comply
with FMCSA’s minimum levels of public liability insurance, and that applicant is required to maintain financial responsibility at the highest level required by any
State within its transit service area (see 49 U.S.C. § 31138 (e) (4)).
Applicant’s transit area lies within the borders of the following State(s): ______________________________________________________________________
Applicant will maintain financial responsibility in the amount of $ ________________________________________
Applicant’s insurance company
□has filed
□will file proof of liability insurance coverage.
Note: Grantees under 49 U.S.C. §§ 5307, 5310, or 5311 that file evidence of State-prescribed financial responsibility limits that are lower than the Federal
limits will be registered to provide interstate service within their designated transit service area only.
b. MOTOR PROPERTY CARRIER
□Applicant
will operate motor vehicles having a gross vehicle weight rating (GVWR) or gross combination weight rating (GCWR) of 10,001 pounds (4,536 kg.) or
more to transport:
□Non-hazardous commodities ($750,000 U.S.)
□Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(c) ($1,000,000 U.S.)
□Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(b) ($5,000,000 U.S.)
□Applicant will only operate motor vehicles having a gross vehicle weight under 10,001 pounds (4,536 kg). Applicant will transport:
□Any quantity of Divisions 1.1, 1.2 or 1.3 explosives, any quantity of poison gas (Division 2.3, Hazard Zone A or Division 6.1, Packing Group 1,
Hazard Zone A materials), or highway route-controlled quantity radioactive materials as defined in 49 CFR 173.455 ($5,000,000 U.S.)
□Applicant will operate vehicles under 10,001 pounds
□Commodities other than those listed above ($300,000 U.S.)
c. PROPERTY BROKER
(Please select one): Applicant’s surety company/financial institution
□Has filed a property broker’s surety bond or trust fund agreement in the amount of $10,000
□Will file a property broker’s surety bond or trust fund agreement in the amount of $10,000
d. SELF-INSURED CARRIERS/FREIGHT FORWARDERS
Applicant has received authorization from FMCSA to self-insure its:
□Bodily Injury and Property Damage (BI&PD) liability
□Cargo liability
□both BI&PD and Cargo liability
and applicant is in full compliance with the conditions of the Agency’s decision authorizing it to self-insure.
MCSA-1 (as of 10-2011)
Page 18 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
e. FREIGHT FORWARDER
□ Applicant will operate as a freight forwarder only and seeks a waiver of BI&PD liability requirements by certifying that in its forwarding operations
applicant: (1) will not own or operate any motor vehicles upon highways in the transportation of property; (2) will not perform transfer, collection, or
delivery services; and (3) will not have motor vehicles operated under its direction and control in the performance of transfer, collection, or delivery
services.
□ Applicant will operate vehicles having Gross Vehicle Weight Ratings (GVWR) of 10,001 pounds or more to transport:
□ Non-hazardous commodities ($750,000 U.S.).
□ Hazardous materials referenced in the FMCSA’s insurance regulations at 49 CFR 387.303(b)(2)(c)($1,000,000 U.S.).
□ Hazardous materials referenced in the FMCSA’s insurance regulations at 49 CFR 387.303(b)(2)(b)($5,000,000 U.S.).
□ Applicant will operate only vehicles having Gross Vehicle Weight Ratings (GVWR) under 10,001 pounds to transport:
□ Any quantity of Classes A or B explosives, any quantity of poison gas (Poison A), or highway route controlled quantity of radioactive materials
($5,000,000 U.S.).
□ Commodities other than those listed above ($300,000 U.S.).
□
Applicant will maintain cargo insurance (HHG freight forwarders only) ($5,000 U.S. / $10,000 U.S.).
f. MOTOR CARRIERS DOMICILED IN MEXICO ONLY
Has applicant operated, or does applicant currently operate, under insurance issued by an insurance or surety company in amounts meeting FMCSA minimum
financial responsibility requirements for periods of 24 hours or longer for movements in the U.S. border commercial zones?
□Yes
□No
See 49 CFR 387.303(b)(4)
g. INSURANCE INFORMATION
Applicant must maintain insurance coverage for bodily injury and property damage
Please provide the following information:
Insurance Company
Address
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Maximum Insurance Amount
_________________________________________________________________________
Policy Number
_________________________________________________________________________
Date Issued
_________________________________________________________________________
Insurance Effective Date
______________________________
Expiration Date __________________________
SELF INSURED for __________BI&PD and _________Cargo or self-insured up to _____________ for BI&PD and/or ____________Cargo.
45. AFFILIATION WITH OTHER FORMER ICC, FHWA, OMCS, OR FMCSA LICENSED ENTITIES
Disclose all relationships applicant now has, or have had in the past 3 years, with other FMCSA-regulated entities. This could be in the form of a percentage of
stock ownership, a loan, or a management position. If this requirement applies to applicant, provide the name of the company, MC/MX/FF-Number, USDOT
Number, and the company’s latest U.S. DOT safety rating. (If applicant requires more space, scan and upload the additional information )
Applicant must indicate whether these entities are currently disqualified from operating commercial motor vehicles anywhere in the United States pursuant to
section 219 of the Motor Carrier Safety Improvement Act of 1999 (MCSIA) (Public Law 106-159, 113 Stat. 1748 (Dec. 9, 1999)).
USDOT #
MCSA-1 (as of 10-2011)
MC/MX/FF No.
Legal Name
DBA Name
Page 19 of 30
Current
Safety Rating
Revoked
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
46. DESIGNATION OF AGENTS FOR SERVICE OF PROCESS
Form No. BOC-3
MCSA-1 (as of 10-2011)
□on file with FMCSA.
□will be filed electronically.
Page 20 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION L.
OMB Control No.: 2126-xxxx
Expires:
SAFETY CERTIFICATIONS (TO BE COMPLETED BY MEXICO-DOMICILED and NON-NORTH
AMERICA-DOMICILED MOTOR CARRIERS)
47. SAFETY CERTIFICATIONS FOR MEXICO-DOMICILED AND NON-NORTH
AMERICA-DOMICILED CARRIERS
a. Applicant maintains current copies of all U.S. DOT Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety
Standards and if applicable the Federal Hazardous Materials Regulations (if a property carrier transporting hazardous
materials), and Federal Motor Carrier Commercial Regulations, understands and will comply with such regulations, and has
ensured that all company personnel are aware of these requirements.
YES
NO
□
□
b. Individual responsible for compliance with applicable regulatory and safety requirements.
Full Name
Complete Address
Position Title
c. Applicant certifies that the following tasks and measures will be fully accomplished and procedures fully implemented before it commences operations in the United
States:
I. DRIVER QUALIFICATIONS
1.
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 age and licensing of each driver, and
procedures for identifying drivers who are not complying with the U.S. safety regulations, and a description of a retraining
and educational program for poorly performing drivers.
2.
The carrier has procedures in place to review drivers’employment and driving histories for at least the last 3 years, to
determine whether the individual is qualified and competent to drive safely.
3.
The carrier has established a program to review the records of each driver at least once every twelve (12) months and will
maintain a record of the review.
4.
The carrier will ensure, once operations in the United States have begun, that all of its drivers operating in the United States
are at least 21 years of age and possess a valid Commercial Driver’s License or a valid Licencia Federal de Conductor (LFC)
and that the driver’s LFC is registered in Mexico’s SCT database.
YES
NO
YES
NO
YES
NO
YES
NO
□
□
□
□
□
□
□
□
II. HOURS-OF-SERVICE
1.
The carrier has in place a record keeping 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.
YES
NO
2.
The carrier has ensured that all drivers to be used in the United States are knowledgeable of the United States’hours-ofservice requirements, and has clearly and specifically instructed drivers about the application to them of the 11-hour, 14-hour,
and 60- and 70-hour rules, as well as the requirement for preparing daily log entries in their own handwriting for each 24hour period.
YES
NO
3.
The carrier has attached, as Attachment F to this application, statements describing the carrier’s monitoring procedures to
ensure that its drivers complete logbooks correctly, and describing the carrier’s record keeping and driver review procedures.
YES
NO
4.
The carrier will ensure, once operations in the United States have begun, that its drivers operate within the hours-of-service
rules and are not fatigued while on duty.
YES
NO
MCSA-1 (as of 10-2011)
Page 21 of 30
□
□
□
□
□
□
□
□
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
III. DRUG AND ALCOHOL (To be completed by motor carriers subject to drug and alcohol testing only)
1.
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
YES
NO
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 U.S. DOT’s
Federal Motor Carrier Safety Regulations and, if applicable, the Federal Hazardous Materials Regulations and the Federal
Commercial Regulations.
YES
NO
2.
The carrier has inspected all vehicles that will be usd in the United States before the beginning of such operations and has
proof of the inspection on board the vehicle as required by 49 CFR 396.17.
YES
NO
3.
The carrier will ensure, once operations in the United States have begun, that all vehicles it operates in the United States were
manufactured or have been retrofitted in compliance with the applicable U.S. DOT Federal Motor Vehicle Safety Standards
or Canadian Motor Vehicle Safety Standards in effect at the time of manufacture.
YES
NO
4.
The carrier will ensure, once operations in the United States have begun, that all violations and defects noted on inspection
reports are corrected before vehicle and drivers are permitted to enter the United States.
YES
NO
5.
The carrier will ensure that all vehicles operated in the United States are inspected at least every 90 days by a certified
inspector in accordance with the requirements for a Level1 Inspection under the criteria of the North American Standard
Inspection, as defined in 49 CFR 350.105, once operations in the United States begin and until such time as the carrier has
held permanent registration from the FMCSA for at least 36 consecutive months. After the 36-month period expires, the
carrier will ensure that all vehicles operated in the United States are inspected in accordance with 49 CFR 396.17 at least once
every 12 months thereafter. (To be completed by Non-North America-domiciled carriers only)
YES
NO
2. The carrier has attached, as Attachment A to this application, the name, address, and telephone number of the person(s)
responsible for implementing and overseeing alcohol and drug programs and the name, address and telephone number of the
drug testing laboratory and alcohol testing services that are used by the company.
□
□
□
□
IV. VEHICLES
1.
-
□
□
□
□
□
□
□
□
□
□
V. ACCIDENT MONITORING
1.
The carrier has in place a program for monitoring vehicle accidents and it maintains an accident register in accordance with
49 CFR 390.15.
YES
NO
2.
The carrier has attached, as Attachment B to this application, a copy of its accident register for the previous 12 months, or a
description of how the company will maintain this register once it begins operations in the United States.
YES
NO
3.
The carrier has established an accident countermeasures program and driver training program to reduce accidents.
YES
NO
4.
The carrier has attached, as Attachment C to this application, a description and explanation of the accident monitoring
program it has implemented for its operations in the United States.
YES
NO
MCSA-1 (as of 10-2011)
Page 22 of 30
□
□
□
□
□
□
□
□
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
VI. PRODUCTION OF RECORDS
YES
NO
YES
NO
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. The HM carrier has
attached a statement providing information concerning (1) the names of employees responsible for ensuring compliance with
HM regulations, (2) a description of their HM safety functions, and (3) a copy of the information used to provide HM
training.
YES
NO
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.
YES
NO
3.
The HM carrier has established a system and procedures for filing and maintaining HM shipping documents.
YES
NO
4.
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
5.
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
YES
NO
1.
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.
2.
The carrier is including as Attachment D to this application the name, address, and telephone number of the employee to be
contacted for requesting records.
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VII. HAZARDOUS MATERIALS (To be completed by motor carriers of hazardous materials only)
1.
2.
TO BE COMPLETED BY CARGO TANK (CT) MOTOR CARRIERS OF HAZARDOUS MATERIALS (HM):
6.
The carrier submitss with this application certficates of compliance for each cargo tank the company utilizes in the U.S.,
together with the name, qualifications, Cargo Tank Facility (CT) number, and CT Facility number registration statement of
the facility it will be utilizing to conduct the test and inspections of such tanks as required by 49 CFR part 180.
MCSA-1 (as of 10-2011)
Page 23 of 30
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UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION M. COMPLIANCE CERTIFICATIONS
AND FREIGHT FORWARDERS)
(TO BE COMPLETED BY MOTOR CARRIERS, BROKERS
48. By signing these certifications, the certifying official is on notice that the representations made herein are subject to
verification through inspections in the United States and through the request for 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.
1.
2.
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 and
desiognation of process agent requirements.
NO
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 Department of Transportation, including
the Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety Standards, Commercial Regulations, Hazardous
Materials Regulations, and Americans With Disabilities Act regulations within 48 hours of any written request. Applicant
understands that the written request may be served on the contact person identified on Page 4 (Section A, Item No. 18), or the
designated process agent.
3.
Applicant is not presently disqualified from operating commercial motor vehicles in the United States.
4.
Applicant understands that the agent(s) for service of process designated on FMCSA Form BOC-3 will be deemed applicant’s
official representative(s) in the United States for receipt of filings and notices in administrative proceedings under 49
U.S.C. § 13303, for receipt of filings and notices issued in connection with the enforcement of any Federal statutes or
regulations.
5.
YES
YES
NO
□
□
YES
□
YES
NO
YES
NO
YES
NO
□
Applicant is not prohibited from filing this application because FMCSA registration is currently under suspension, or was
revoked less than 30 days before the filing of this application.
□
□
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TO BE COMPLETED ONLY BY A NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
6.
Applicant is willing and able to have all vehicles operated in the United States inspected at least every 90 days by a certified
inspector and have decals affixed attesting to satisfactory compliance with applicable inspection criteria. This requirement
will end after applicant has held permanent registration from FMCSA for three consecutive years.
7.
If applicant’s registration has been revoked, the deficiencies cited in the revocation proceeding have been corrected.
Applicant is providings an explanation of how it has corrected these deficiencies and how it will otherwise ensure that basic
safety management controls are maintained.
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED MOTOR CARRIER
8.
Applicant has paid all taxes owed under section 4481 of the U.S. Internal Revenue Service (26 U.S.C. § 4481) for the most
recent taxable period as defined under section 4482 (c) of the Internal Revenue Code.
□
YES
□
NO
□
N/A
□ □
YES
□
NO
□
______________________________________________________________
Signature
NOTE: All motor carriers operating within the United States, including foreign-domiciled motor carriers applying for USDOT registration by this form, must comply with
all applicable 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 an OSHA state plan agency pursuant to
section 18 of the Occupational Safety and Health Act of 1970. 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.
MCSA-1 (as of 10-2011)
Page 24 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
SECTION N. APPLICANT’S OATH
49. This oath applies to all supplemental filings to this application. The signature must be that of an authorized official of the applicant, not the legal
representative.
I, ____________________________________________________, verify under penalty of perjury, under the laws of the United States of America,
(PRINT NAME)
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 of up to 5 years and fines up to $250,000 for each offense. Additionally these statements are punishable as perjury
under 18 U.S.C. § 1621, which provides for fines of up to $250,000 or imprisonment of 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 of 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, formerly Pub. L. 100-690,
Title V, Section 5301, Nov. 18, 1988, 102 Stat. 4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002 (d), Nov. 29, 1990, 104 Stat.
4827) (21 U.S.C. 862).
Signature ___________________________________
MCSA-1 (as of 10-2011)
Title _______________________________
Page 25 of 30
Date____________________
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
SECTION O.
50.
OMB Control No.: 2126-xxxx
Expires:
FILING FEE INFORMATION (FMCSA does NOT refund filing fees)
TYPE OF FILING: (Check all boxes that apply)
New Registration
For-hire or Motor Private Carrier (except FTA grantees)
Freight Forwarder
Broker
Inter modal Equipment Pr ovider
Car go Tank Facility
Total Number of Boxes Checked
__ x $300 = $ _______________
Total
Reinstatement
FTA Grantee
All Other
$10
No Fee
No Fee
METHOD OF PAYMENT (Check one):
□ ELECTRONIC FUNDS TRANSFER (EFT)
BANK NAME: ______________________________________________________________________________
□□□□□□□□□□□□□□□□□□□□□□□
CHECKING ACCOUNT NUMBER: □
□□□□□□□□□□□□□□□□□□□□□
BANK ROUTING NUMBER:
□ VISA
Credit Card Number:
□ MASTERCARD
□ DISCOVER
□□□□□□□□□□□□□□□□
□ AMERICAN EXPRESS
Credit Card Expiration Date: ____/____/______
Month
Day
Year
Print Name of the person who the credit card is issued to: ___________________________________________________________
Signature of the person authorizing use of the credit card: ___________________________________________________________
Date the application was completed: _________________________________
FEE POLICY
•
•
•
•
•
FMCSA does not refund filing fees.
Your filing fees must be payable to the Federal Motor Carrier Safety Administration, by Electronic Funding Transfer, or by
an approved credit card.
Electronic Funding Transfers must be from an account in a bank in the United States.
Fees are required for each type of registration requested. Applicant may select more than one type of registration on a single
Form MCSA-1, and submit a single payment for the total fees due. For example, if applicant wishes to be registered as both a
motor carrier and a broker, applicant may file a single Form MCSA-1 and make a single payment of $600.
FMCSA will not process an applicant’s Form MCSA-1until the payment has been deducted from his/her banking or credit card
account.
MCSA-1 (as of 10-2011)
Page 26 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
ATTACHMENTS TO SECTION L
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
ATTACHMENT A
FOR SECTION L, 47
DRUG AND ALCOHOL TESTING
(BOX III 2)
Below applicant has listed:
(1) The name, address and position of the person or persons designated by applicant as responsible for implementing and overseeing its alcohol and drug
testing programs.
(2) The name, address, and telephone number of both its drug testing laboratory and its alcohol testing service. If the alcohol testing service information
is identical to the information for the drug testing laboratory, applicant should enter “Same” in the space for the alcohol testing service.
NAME
ADDRESS
POSITION
NAME OF DRUG TESTING LABORATORY
ADDRESS
TELEPHONE NUMBER
NAME OF ALCOHOL TESTING SERVICE
ADDRESS
TELEPHONE NUMBER
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
ATTACHMENT B
FOR SECTION L, 47
ACCIDENT REGISTER
(BOX V 2)
□ Applicant is attaching a copy of its accident register for the last 12 months.
□ Applicant is beginning operations and the following explains how it will maintain its accident register once it begins operations in the U.S.:
MCSA-1 (as of 10-2011)
Page 27 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
ATTACHMENT C
FOR SECTION L, 47
ACCIDENT MONITORING PROGRAM
(BOX V 4)
The following fully describes applicant’s accident monitoring program for operations in the U.S.:
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
ATTACHMENT D
FOR SECTION L, 47
PRODUCTION OF RECORDS
(BOX VI 2)
The following individual(s) is directed by applicant to respond to inquiries for records:
NAME
MCSA-1 (as of 10-2011)
ADDRESS
Page 28 of 30
TELEPHONE NUMBER
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED HAZARDOUS
MATERIALS MOTOR CARRIER
ATTACHMENT E
FOR SECTION L, 47
HAZARDOUS MATERIALS (HM)
(BOX VII 2)
Applicant is attaching a copy of the materials we employ to provide HM training. Below applicant has listed its employees (other than drivers) who are
responsible for ensuring compliance with HM regulations and a description of the HM safety functions of each employee. Applicant has also attached a
copy of its training materials.
EMPLOYEE
MCSA-1 (as of 10-2011)
DESCRIPTION OF HM SAFETY FUNCTION
Page 29 of 30
UNITED STATES DEPARTMENT
OF TRANSPORTATION
Federal Motor Carrier Safety Administration
OMB Control No.: 2126-xxxx
Expires:
TO BE COMPLETED ONLY BY A MEXICO-DOMICILED OR NON-NORTH AMERICA-DOMICILED MOTOR CARRIER
ATTACHMENT F
FOR SECTION L, 47
HOURS-OF-SERVICE MONITORING PROGRAM
(BOX II 3)
Applicant has attached to this application statements describing the monitoring procedures designed to ensure that its drivers complete log books correctly, and also
describing its procedures for record keeping and review of drivers. If applicant has drivers operating under the 100 air-mile exception, applicant described the maintenance
of these records by means of an attachment to this document.
MCSA-1 (as of 10-2011)
Page 30 of 30
| File Type | application/pdf |
| File Title | IDENTIFICATION AND REGISTRATION APPLICATION |
| Author | jmontagu |
| File Modified | 2011-10-26 |
| File Created | 2011-10-25 |