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