MLC CARRIER PROFILE FORM
Fill out the form carefully for registration
Driver's Legal Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you a owner/operator?
*
Yes
No
Company Name or DBA:
If no company, leave blank.
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Insurance Information
*
Company Name, Company Address, Type of Coverage
Company Phone Number
-
Area Code
Phone Number
Do you have a Factoring Company?
*
Yes
No
US DOT Number
*
MC Number
*
Truck YMM
*
Year, Make, & Model
Truck Number
*
Type of Trailer
*
Dry Van, Flatbed, Reefer, etc.
Trailer Size
*
Trailer Number
*
Equipment
*
Do you have Tarps, Straps, etc.
Truck's Domicile Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Geographical Lanes
*
SouthWestern States
West Coast States
SouthEastern States
NorthWestern States
MidWest States
Driving Distance
*
Local (Home Daily)
Regional (1-3 nights/week)
OTR (Out 5 nights or more)
All of the Above
List Any Specific Preferred Lane Details:
Preferred Type of Freight:
*
Max Weight Will Transport
*
Minimum Mileage Rate You Will Accept:
*
Max Mileage You Are Willing to Travel:
*
# of Miles or Hours Per Day
Additional Comments
If you have any discrepancies on MC #, please explain
Upload Docs
Browse Files
MC Letter, COI, W9, etc
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of
Signature
*
I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application or immediate termination of my membership.
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