National Carrier Intake Form

1
Business Name* This field is required.
2
MC Number* This field is required.
3
USDOT Number* This field is required.
4
Equipment Type* This field is required.
Please Select
Please Select
Class A
Class B
Box Truck
5
Years in Business* This field is required.
Please Select
Please Select
Less than 1 year
1-2 years
3-5 years
6-10 years
More than 10 years
6
Violation Count* This field is required.
Please Select
Please Select
0-2
3-4
5+
7
Do you have a valid CDL or Driver's License?* This field is required.
Yes
No
8
Do you have any DUI/DWI history?* This field is required.
Yes
No
9
Disqualification Notice
10
Which program are you applying for?* This field is required.
Standard (8%)
New Authority (10%, then reduction to 8%)
Rescue Program (0%)
11
Upload Final Repair/Tow Invoice (Rescue Program applicants only)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
12
Copy of Valid Driver’s License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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13
Certificate of Insurance ($100k Cargo / $1M Liability)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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14
FMCSA Authority Letter* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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15
Signed W-9 Form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
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16
Equipment Photo (Truck/Trailer)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
17
Terms and Conditions & Load Integrity Protocol (4-point photo requirement)* This field is required.
18
E-signature (Legally Binding)* This field is required.
19
I agree to the 7-load performance trial and automatic enrollment.* This field is required.
I agree
Should be Empty: