MCS-150B Combined Motor Carrier Identification Report and HM Perm

Form MCS-150B (Revised: 12/20/2012)

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 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 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

Combined Motor Carrier Identification Report and HM Permit Application
(Application for USDOT Number)

REASON FOR FILING (mark only one)
NEW APPLICATION

BIENNIAL UPDATE OR CHANGES

REAPPLICATION (AFTER REVOCATION OF NEW ENTRANT)

OUT OF BUSINESS NOTIFICATION

1. LEGAL BUSINESS NAME

2. DOING BUSINESS AS NAME (if different from Legal Business Name)

3. PRINCIPAL PLACE OF BUSINESS

4. CITY

5. STATE/PROVINCE

6. ZIP CODE

7. COLONIA (MEXICO ONLY)

8. MAILING ADDRESS

9. CITY

10. STATE/PROVINCE

11. ZIP CODE

12. COLONIA (MEXICO ONLY)

13. PRINCIPAL BUSINESS PHONE NUMBER

16. USDOT NUMBER

14. PRINCIPAL CONTACT CELL PHONE NUMBER

17. MC OR MX NUMBER

18. DUN & BRADSTREET NUMBER

20. E-MAIL ADDRESS

15. PRINCIPAL BUSINESS FAX NUMBER

19. IRS/TAX ID NUMBER *See instructions before completing this section.

21. CARRIER MILEAGE (to nearest 10,000 miles for the previous 12 months)

22. COMPANY OPERATIONS (mark all that apply)
Interstate Carrier
A.
B.
Intrastate Hazmat Carrier

C.

D.

Intrastate Non-Hazmat Carrier

23. OPERATION CLASSIFICATIONS (mark all that apply)
D.
A.
Private Motor Carrier of Passengers (Business)
Authorized For-Hire
E.
B.
Private Motor Carrier of Passengers (Non-Business)
Exempt For-Hire
F.
C.
Migrant
Private Property

G.
H.
I.

E.

Interstate Hazmat Shipper
J.
K.
L.

U.S. Mail
Federal Government
State Government

Intrastate Hazmat Shipper

Local Government
Indian Tribe
Other

(what kind of broker, Property or Household Goods, should be written in)

24. CARGO CLASSIFICATIONS (mark all that apply)
A.
B.
C.
D.
E.
F.

G.
H.
I.
J.
K.
L.

GENERAL FREIGHT
HOUSEHOLD GOODS
METAL: SHEETS, COILS, ROLLS
MOTOR VEHICLES
DRIVE AWAY/TOWAWAY
LOGS, POLES, BEAMS, LUMBER

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

S

B

NB

C
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.

DIV 1.1
DIV 1.2
DIV 1.3
DIV 1.4
DIV 1.5
DIV 1.6
DIV 2.1 (Flam. Gas)
DIV 2.1 LPG
DIV 2.1 (Methane)
DIV 2.2

S

B

S.
T.
U.
V.
W.
X.

PASSENGERS
OIL FIELD EQUIPMENT
LIVESTOCK
GRAIN, FEED, HAY
COAL/COKE
MEAT

(C) CARRIER

25. HAZARDOUS MATERIALS (CARRIER OR SHIPPER) (mark all that apply)
C

M.
N.
O.
P.
Q.
R.

BUILDING MATERIALS
MOBILE HOMES
MACHINERY, LARGE OBJECTS
FRESH PRODUCE
LIQUIDS/GASES
INTERMODAL CONTAINER

(S) SHIPPER

(B) BULK – IN CARGO TANKS

NB

C
U.
V.
W.
X.
Y.
Z.
AA.
BB.
CC.
DD.

DIV 2.2D (Ammonia)
DIV 2.3A
DIV 2.3B
DIV 2.3C
DIV 2.3D
CLASS 3
CLASS 3A
CLASS 3B
COMB LIQ
DIV 4.1

Y.
Z.
AA.
BB.
CC.
DD.

GARBAGE, REFUSE, TRASH
U.S. MAIL
CHEMICALS
COMMODITIES DRY BULK
REFRIGERATED FOOD
BEVERAGES

S

B

PAPER PRODUCT
UTILITY
FARM SUPPLIES
CONSTRUCTION
WATER WELL
OTHER

(NB) NON-BULK – IN PACKAGES
EE.
FF.
GG.
HH.
II.
JJ.
KK.
LL.
MM.
NN.
OO.

NB

DIV 4.2
DIV 4.3
DIV 5.1
DIV 5.2
DIV 6.1A
DIV 6.1B
DIV 6.1 POISON
DIV 6.1 SOLID
DIV 6.2
CLASS 7

C

S

B

NB

HRCQ
CLASS 8
CLASS 8A
CLASS 8B
CLASS 9
ELEVATED TEMP MAT.
INFECTIOUS WASTE
MARINE POLLUTANTS
HAZARDOUS SUB (RQ)
HAZARDOUS WASTE
ORM

26. NUMBER OF VEHICLES THAT WILL BE OPERATED IN THE U.S.
Number of vehicles carrying number of passengers (including the driver)
Straight
Trucks

Truck
Tractors

Trailers

Hazmat Cargo
Tank Trucks

Hazmat Cargo
Tank Trailers

Motorcoach

School Bus
1-8

OWNED
TERM LEASED
TRIP LEASED
27. DRIVER INFORMATION

INTERSTATE

9-15

INTRASTATE

16+

Bus

Passenger Van

16+

9-15

TOTAL DRIVERS

Beyond 100-Mile Radius

If yes, enter your USDOT Number:

Yes

1-8

9-15

TOTAL CDL DRIVERS

Within 100-Mile Radius

28. IS YOUR USDOT NUMBER REGISTRATION CURRENTLY REVOKED BY THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION?

16+

Limousine

No

16+

Form MCS-150B (Revised: 12/20/2012)

29. COMPLIANCE CERTIFICATION
ALL MOTOR PASSENGER CARRIER APPLICANTS must certify as follows:
Applicant is fit, willing, and able to provide the proposed operations and to comply with all pertinent 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.
YES
Private entities that are primarily in the business of transporting people, whose operations affect commerce, and that transport passengers in an overthe-road 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. For a general overview of these regulations, go to the
Federal Motor Carrier Safety Administration’s Web site at www.fmcsa.dot.gov/rules-regulations/bus/company/ada-guidelines.htm.
30. WHICH OF THE FOLLOWING HAZARDOUS MATERIALS 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 (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 liters (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 liters (3,500 gallons).

31. IF YOU CHECKED QUESTION 30, ARE YOU APPLYING FOR OR RENEWING A HM SAFETY PERMIT? (please check one)

Initial

Renewal

33. DOES YOUR COMPANY CERTIFY THAT THEY HAVE A SATISFACTORY SECURITY PROGRAM IN PLACE
AS REQUIRED IN 49 CFR PART 385, SUBPART E?

Yes

No

34. IS YOUR COMPANY REQUIRED BY ANY STATE(S) TO HAVE A PERMIT FOR ANY OF THE HAZARDOUS
MATERIALS LISTED IN QUESTION 30?

Yes

No

32. 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 365 DAYS?

35. IF YOUR ANSWER TO QUESTION 34 IS YES, CHECK THE STATE(S) IN WHICH YOU HAVE THE PERMIT:
AK

AL

AR

AZ

CA

CO

CT

DC

DE

FL

GA

HI

IA

ID

IL

IN

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

VA

VT

WA

WI

WV

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.

36. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S), PARTNERS OR OFFICERS AND TITLES (e.g. president, treasurer, general partner, limited partner)
1.

2.

37. CERTIFICATION STATEMENT (to be completed by authorized official)
I,
, 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.
Signature

Title

Date
(please print)