MCS-150C Intermodal Equipment Provider Identification Report

Form MCS-150C (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

Intermodal Equipment Provider Identification Report
(Application for USDOT Number)

REASON FOR FILING (mark only one)
NEW APPLICATION

BIENNIAL UPDATE OR CHANGES

1. LEGAL BUSINESS NAME

OUT OF BUSINESS NOTIFICATION

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

14. PRINCIPAL CONTACT CELL PHONE NUMBER

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

15. PRINCIPAL BUSINESS FAX NUMBER

Yes

No

If yes, enter your USDOT Number:
17. DUN & BRADSTREET NUMBER

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

19. E-MAIL ADDRESS

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

21. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S), PARTNERS OR OFFICERS AND TITLES (e.g. president, treasurer, general partner, limited partner)
2.

1.
22. 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)