OP-1 Application for Motor Property Carrier and Broker Author

Form OP-1 (Revised: 03/05/2014)

OMB No. 2126-0016

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 2126-0016. Public reporting for this collection of information is estimated to be
approximately 2 hours 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 the Freedom of Information Act (FOIA). 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.

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

FORM OP-1 APPLICATION FOR MOTOR PROPERTY CARRIER AND BROKER AUTHORITY
FOR FMCSA USE ONLY
Docket No. MC

Fee No.

This application is for all businesses requesting Operating
Authority as a motor carrier, broker, and/or U.S.-based enterprise
carrier of property or household goods.
Filed

CC Approval No.

SECTION I — Applicant Information
1. Do you now have authority from or an application being processed
by the FMCSA, FHWA, OMCS, or ICC?
2. LEGAL BUSINESS NAME

Yes

No

If yes, identify the MC/FF Number
(or lead docket number):
3. DOING BUSINESS AS NAME (if different from Legal Business Name)

PRINCIPAL ADDRESS (PRINCIPAL PLACE OF BUSINESS)
4. STREET NAME AND NUMBER (No P.O. Box)

5. CITY

6. STATE

7. ZIP CODE

8. TELEPHONE NUMBER

9. FAX NUMBER

11. CITY

12. STATE

13. ZIP CODE

14. TELEPHONE NUMBER

15. FAX NUMBER

MAILING ADDRESS (if different from Principal Address above)
10. STREET NAME AND NUMBER

REPRESENTATIVE (person who can respond to inquiries)
17. TITLE, POSITION, OR RELATIONSHIP TO APPLICANT

16. NAME

18. STREET NAME AND NUMBER

19. CITY

20. STATE

21. ZIP CODE

22. TELEPHONE NUMBER

23. FAX NUMBER

24. USDOT NUMBER (if available; if not, see instructions)

FORM OF BUSINESS (select only one)
25. CORPORATION

STATE OF INCORPORATION

26. SOLE PROPRIETORSHIP LEGAL NAME OF OWNER
27. PARTNERSHIP

LEGAL NAME OF EACH PARTNER

SECTION II — Type of Operating Authority (select at least one)
28. Check box(es) for each type of Operating Authority requested. You must submit a filing fee of $300.00 for each box checked.
Motor Common Carrier of Property (except Household Goods)

Broker of Property (except Household Goods)

Motor Contract Carrier of Property (except Household Goods)

Broker of Household Goods

Motor Common Carrier of Household Goods

United States-based Enterprise Carrier of International Cargo (except Household Goods)

Motor Contract Carrier of Household Goods

United States-based Enterprise Carrier of International Household Goods

SECTION III — Insurance Information (Applicants that will operate commercial motor vehicles must complete this section.)
29. 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 FMCSA.
(Refer to the instructions for information about cargo insurance requirements for motor common carriers and United States-based enterprise carriers, and surety bond/trust fund agreement filings for brokers.)
Applicant will operate one or more vehicle(s) having a gross vehicle weight rating (GVWR) of 10,000 pounds or more to transport:
Non-hazardous commodities ($750,000)
Hazardous materials referenced in FMCSA's insurance regulations at 49 CFR 387.9 ($1,000,000)
Hazardous materials referenced in FMCSA's insurance regulations at 49 CFR 387.9 ($5,000,000)
Applicant will operate only vehicles having gross vehicle weight ratings (GVWR) under 10,000 pounds to transport:
Any quantity of Division 1.1, 1.2, or 1.3 material; any quantity of Division 2.3, Hazard Zone A, or Division 6.1, Packing Group I, Hazard Zone A material; or highway route controlled
quantities of a Class 7 material as defined in 49 CFR 173.403 ($5,000,000)
Commodities other than those listed above ($300,000)

Form OP-1 (Revised: 03/05/2014)

SECTION IV — Safety Certification (for vehicle-operating applicants only). Select only one.
30. APPLICANTS SUBJECT TO FEDERAL MOTOR CARRIER SAFETY REGULATIONS.
If you will operate vehicles of more than 10,000 pounds GVWR and are, thus, subject to pertinent portions of the USDOT's Federal Motor Carrier Safety Regulations (FMCSRs) 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 USDOT regulations relating to the safe operation of commercial vehicles and the safe transportation of hazardous materials,
and 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 FMCSRs. (2) Can produce a copy of the FMCSRs 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 391). (6) Has in place policies and procedures consistent with USDOT regulations governing driving and operational safety of
motor vehicles, including drivers' hours of service and vehicle inspection, repair, and maintenance (49 CFR 392, 395, and 396). (7) Is familiar with, and will have in place on the
appropriate effective date, a system for complying with USDOT regulations governing alcohol and controlled substances testing requirements (49 CFR 382 and 40).

Yes

31. EXEMPT APPLICANTS.
If you will operate only small vehicles (GVWR under 10,000 pounds) and will not transport hazardous materials, you are exempt from FMCSRs, and must certify as follows:
Applicant is familiar with and will observe general operational safety guidelines, as well as any State and local laws and requirements relating to the safe operation of commercial
motor vehicles and the safe transportation of hazardous materials.

Yes

SECTION V — Affiliations
32. Disclose any relationship you have or have had with any other FMCSA-regulated entity (including entities licensed by the FHWA, OMCS, or ICC) within the past 3 years. Examples include, but are
not limited to, a percentage of stock ownership, a loan, or a management position. If this requirement applies to you, provide the name of the company, MC/FF Number, USDOT Number, and
that company's latest DOT safety rating. If you require more space, attach the information to this application form.

SECTION VI — Household Goods Certifications
33. HOUSEHOLD GOODS MOTOR COMMON CARRIER APPLICANTS including United States-based Enterprise Carriers of International Household Goods 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, FHWA, or OMCS, 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

34. HOUSEHOLD GOODS MOTOR CONTRACT CARRIER APPLICANTS including United States-based Enterprise Carriers of International Household Goods 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, FHWA, or OMCS, 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 USC 13101.

Yes

35. 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 USC 13101.

Yes

Applicant may attach a supporting statement to this application to provide additional information about any of the above certifications. This evidence is optional.

SECTION VII — Scope of Operating Authority (only applicants requesting operating authority as a Motor Contract Carrier of Household Goods must complete this section; check all boxes that apply)
36. Contracting shippers have one or more of the distinct needs delineated in Interstate Van Lines, Inc., Extension — Household Goods, 5 I.C.C.2d 168 (1988). Describe briefly the distinct need(s):

37. Contracts provide for assignment of one or more vehicles for the exclusive use of each shipper in the manner specified in Interstate Van Lines, Inc., Extension — Household Goods,
5 I.C.C.2d 168 (1988).

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.

SECTION VIII — Applicant's Oath
38. This oath applies to all supplemental filings to this application. The signature must be that of the applicant, not a legal representative. Print name in the first blank space.

, verify under penalty of perjury, under the laws of the United States of America, that all information
I,
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 USC 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 USC 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, a, 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 USC 862).
Finally, I certify that the applicant is not domiciled in Mexico, or owned or controlled by persons of that country. (Note: This portion of the Applicant's Oath does not
pertain to applicants that are U.S.-based enterprises owned or controlled by persons of Mexico seeking to provide truck services for the transportation of international cargo.)

Signature

Title

Date

Form OP-1 (Revised: 03/05/2014)

Payment Instructions
(1) Each type of Operating Authority requested in Section II of the application form requires a $300 processing fee. This fee is NON-REFUNDABLE.
Calculate the total amount due as follows:
× $300 =
Number of boxes checked in Section II

Total payment due

(2) Select payment method:
Check or Money Order — Make payable to FMCSA in United States currency. Payment must be drawn upon funds deposited in a bank located in the United States.
Credit Card — Complete the Credit Card Payment Authorization below.
Credit Card Payment Authorization
Select Credit Card:

Visa

MasterCard

Credit Card Number:

Expiration Date:

Name (exactly as it appears on card):

Payment Amount:

Credit Card Billing Address
Street Name and Number:
State:

City:
Signature:

Zip Code:
Payment Date:

Mailing Instructions (to apply online, please see "How to Apply" [Topic II] in the instructions)
(1) Save a copy of the completed application form(s), all supporting documents (if any), and payment details for the company's business records.
(2) Depending upon the type of payment and method of mail delivery, send the completed application form(s), any supporting documents, and payment to one of the following addresses.
Note: Sending payment to the wrong address will delay application processing by 2-3 weeks.
Check or Money Order:
Standard First-Class Mail
Federal Motor Carrier Safety Administration
P.O. Box 530226
Atlanta, GA 30353-0226
Express Mail Only
Bank of America
Lockbox #530226
1075 Loop Road
Atlanta, GA 30337

Credit Card:
Federal Motor Carrier Safety Administration
1200 New Jersey Avenue SE, MC-RS
Washington, DC 20590