Form 1 Motor Carrier Application Form

OMB Control Number: XXXX-XXXX Expiration Date: MM/DD/YYYY

UNDER 21 MILITARY COMMERCIAL DRIVERS PILOT PROGRAM

MOTOR CARRIER APPLICATION FORM

Privacy Statement

• Authority: 49 CFR 381.400; Pub. L. 114-94, Dec. 4, 2015, 49 USC 31315 Section 5404

• Purpose: FMCSA will be collecting this data for use in the research effort title “Pilot Program to Allow 18- to 21-Year-Old Persons with Military Driving Experience to Operate Commercial Motor Vehicles (CMVs) in Interstate Commerce”. Additionally, this data may be used for future undetermined research efforts, but cannot be used for enforcement purposes.

• Routine Uses: In addition to those disclosures permitted under 5 USC 552a(b) of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transportation (DOT) Prefatory Statement of General Routine Uses published in the Federal Register on December 29, 2010 (75 FR 82132), under ‘‘Prefatory Statement of General Routine Uses’’ (available at http://www.dot.gov/privacy/privacyactnotices).

• Disclosure: The disclosure of this data is voluntary, however, failure to provide the requested information may result in dismissal from participating in the pilot program. For drivers granted privilege to operate under an exemption through this program, dismissal from the pilot program will result in the denial to continue operating under that exemption.

This form is to be used by carriers/employers who wish to participate in the Under 21 Military Pilot. Military service members of the armed forces, including Reserves and National Guard may apply for the Under 21 Military Commercial Driver License (CDL) Pilot. Driver applicants for this pilot must be currently licensed with both a State and military driver’s license. Driver applicants must currently be or have been employed within the last year in a military position requiring the operation of a military motor vehicle equivalent to a commercial motor vehicle (CMV) as indicated on the driver’s application and waiver form.

APPLICANT INFORMATION

MOTOR CARRIER NAME

MOTOR CARRIER NUMBER OR DOT NUMBER (required)

APPLICATION DATE

DOING BUSINESS AS

PHONE NUMBER

EMAIL ADDRESS

MOTOR CARRIER ADDRESS (PO BOX NUMBER)

CITY

STATE

COUNTY

ZIP CODE

GENERAL INFORMATION

INTERSTATE AND / OR INTRASTATE

_{INTERSTATE  INTRASTATE  BOTH}

FLEET SIZE

WHAT CDL CLASS DO YOUR DRIVERS HAVE?

_{CLASS A  CLASS B  CLASS C  ALL  MIXTURE}

WHAT IS YOUR DRIVER TURNOVER RATE?

WHAT STATES DO YOUR DRIVERS TRAVEL THROUGH?

WHAT IS YOUR PAY STRUCTURE? (hourly, miles, load, etc.)

MILES TRAVELED

If you currently operate Interstate, please state the number of Control Group drivers you hope to provide for this pilot.

If you currently operate Intrastate, please state the number of 18-20 year old Intrastate drivers you hope to provide for this pilot.

Please state the number of Under 21 Military drivers you hope to employ in this pilot.

Please list what type of equipment you currently have installed as well as other technologies being used. Electronic logging device	Rail
	Long Haul
	Truckload

	Rail / Intermodal
	Long Haul
	Truckload
	Short Haul
	Less than truckload


TYPE OF CARRIER OPERATION (CHECK ALL THAT APPLY)

TYPES OF COMMERCIAL MOTOR VEHICLES YOU EMPLOY

	Dump Trucks		Box or Straight Truck
	Minivan		Agricultural Truck
	Flatbed Truck		Trunk Tractor
	Cement Mixer		Cargo van
	Car Carrier		Delivery Van
	Hearse		Pump Truck
	Tank Truck		Tow Truck

TYPES OF COMMERCIAL MOTOR VEHICLES YOU EMPLOY (CHECK ALL THAT APPLY)

	Dump Trucks (B)		Box or Straight Truck (B)
	Minivan (C / H)		Agricultural Truck (A / B)
	Flatbed (A)		Trunk Tractor
	Cement Mixer (A / B)		Cargo van (C / H)
	Car Carrier (A)		Pumper (A / B)
	Tanker (A)		Tow (A / B)

I certify under penalty of perjury that the information on this form is true and correct to the best of my knowledge, information and belief. I certify that I am in complete compliance with the Federal Motor Carrier’s Safety Regulations (FMCSRs). I certify that I have verified all of my driver applicant’s information with his / her Commanding Officer.

Name of Point of Contact completing this application

Signature

Public Burden Statement

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 XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately XX minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. All responses to this collection of information are voluntary. 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.