Business Information
Company Name
*
Contact Person
Name
*
Title
Phone
*
Email
*
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOT Number
MC Number (if applicable)
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Driver Information
Total Number of Drivers
Types of Drivers
Company Drivers
Owner-Operators
Temporary/Contract Drivers
Total Number of CDL/CLP Drivers (if any)
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Vehicle Information
Total Number of Vehicles
Types of Vehicles
Truck Tractors
Trailers
Straight Trucks
Other (please specify):
Do you have commercial motor vehicles or a combination of vehicle and trailer with a GVW or GVWR of 26,001 lbs. or more?
Yes
No
Are you currently enrolled in a Random Drug and Alcohol Consortium Program?
Yes
No
Does Not Apply
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Operation Classification
Check all that apply
Interstate
Intrastate Hazmat
Intrastate Non-Hazmat
Private (Property)
For-Hire (Property)
For-Hire (Passenger)
Exempt
Other
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Cargo Information
Types of Cargo Hauled (check all that apply)
General Freight
Household Goods
Metal: sheets, coils, rolls
Motor Vehicles
Logs, Poles, Beams, Lumber
Building Materials
Mobile Homes
Machinery, Large Objects
Fresh Produce
Liquids/Gases
Intermodal Containers
Passengers
Oilfield Equipment
Livestock
Grain, Feed, Hay
Coal/Coke
Meat
Garbage, Refuse, Trash
US Mail
Chemicals
Commodities Dry Bulk
Refrigerated Food
Beverages
Paper Products
Utilities
Agricultural/Farm Supplies
Construction
Water Well
Other
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Areas of Concern
Please indicate any specific areas of concern:
CSA Scores
Yes
No
CSA Scores Details
Insurance Coverage Issues
Yes
No
Insurance Coverage Issues Details
Safety Measurement System (SMS) Violations
Yes
No
Safety Measurement System (SMS) Violations Details
Load Acquisition Problems
Yes
No
Load Acquisition Problems Details
Other Compliance Issues
Yes
No
Other Compliance Issues Details
Additional Comments or Information
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