BLUE RIDGE TM LLC
Broker Authority Application
OWNER INFORMATION
Owner Name
*
First Name
Last Name
Owner Title
Owner SSN#
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
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BUSINESS INFORMATION
Legal Business Name
*
DBA Name (Doing business as, if not an INC or LLC)
Business Address (no po box)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If this is a Canadian address, what is the NCS Code (National security code)?
Type of Business (legal)
*
Sole proprietorship
LLC (limited liability Company)
INC
LLC Partnership
Other
If a Corporation, what State was the Corporation filed in?
Business EIN
Contact Name (if different)
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Email
*
example@example.com
Do you want to be added to our email communications/ contact list? We mail out industry changes, notifications, news and updates
*
Yes
No
Partner Name
First Name
Last Name
Partner SSN
Partner Name
First Name
Last Name
Partner SSN
Partner Name
First Name
Last Name
Partner SSN
Do you have a USDOT #
*
Yes
No
USDOT #
Is this company owned or controlled by a citizen of the United States?
*
Yes
No
Is this company owned or controlled by a citizen of Canada?
*
Yes
No
Is this company owned or controlled by a citizen of Mexico?
*
Yes
No
Is this company owned or controlled by a citizen of another Foreign Country?
*
Yes
No
If you answered yes to the above question, which Country?
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Filings Being Ordered
Check mark which filings you need
Check filings needed
*
Trucking Authority
Broker Authority
USDOT #
BOC3
UCR
KYU
NM WDT Permit
NY HUT Permit
IFTA Tax reporting
LLC Formation
Haz Mat License
SCAC Code
Canadian Authority
ACE/ACI Manifest
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Certification Statement
All questions must be answered honestly. These questions are required
Does the applicant currently have, or has had within the last 3 years of the date of filing this application, relationship involving common stock, common ownership, common management, common control of a previous DOT or MC Number? If so please provide information on those below
*
No
Yes
DOT #
MC #
Pin Number (s)
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Certification Statement-Authorized Signer/Owner must initial each item
You are familiar with the Federal Hazardous Material Regulations. Under penalties of perjury, you declare that the information entered on this report is, to the best of your kmowledge and belief, true, correct and complete.
*
Initial here
Do you certify that your willing and able to provide the proposed operations or service and to comply with all pertinent statutory and regulatory requirements and regulations issued or administered by the US Department of Transportation, including operational regulations, safety fitness requirements, motor vehicle safety standards and minimum financial responsibility and designation of process agent requirements?
*
Initial here
I certify that I am willing and able to produce for review or inspection documents which are requested for the purpose of determining compliance with applicable statutes and regulations administered by the Department of Transportation, including the Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety Standards, Commercial Regulations, Hazardous Materials Regulations, and Americans with Disabilities Act regulations within 48 hours of any written request? Applicant understands that the written request for documents may be served on the contact person identified in the company contact section of this application, or the designated process agent?
*
Initial here
I certify that I am willing and able to have all vehicles operated in the United States inspected at least every 90 days by a certified inspector and have decals affixed attesting to satisfactory compliance with applicable inspection criteria. This requirement will end after applicant has held permanent registration from FMCSA for three consecutive years?
*
Initial here
I certify that I am not prohibited from filing this application because its FMCSA registration is currently under suspension, r was revoked less thatn 30 days before filing the application?
*
Initial here
I verify under penalty of perjury, under the laws of the United States of America, that all information supplied on this form or related to this application is true and correct. Further, I certify that I am qualified and authorized to file this application.
*
Initial here
I further certify, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State offense involving the distribution of possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits, either by court order or operation of law.
*
Initial here
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Power of Attorney
As grantor, do herby make and constitue and appoint Blue Ridge TM LLC with the office location in Hiawassee, Ga as my true and lawful Attorney-in-fact, to act in my name, place and stead, on my behalf, and for my use and benefit, the following specific acts: 1. IFTA fuel tax reporting 2.Filing of US DOT applications, applying for authorities, to file applications to secure permits and to pay fees to various State agencies. 3. INC or LLC filings. Giving us the ability to file and sign on your behalf in order to obtain filings in order to set up your company for you. Giving us the ability to complete the filing that you paid us for.
*
Owner/Authorized-Signature
Grantor indemnifies and hold Attorney-in-fact harmless from any liability or obligation related to the grantor's conduct of its business. The only responsibility of Attorney-in-fact relates to the specific limited powers specified above. My Attorney-in-fact shall be compensated based on a fee schedule provided to grantor by Attorney-in-fact, and all payments shall be made in advance.
*
Owner/Authorized signature
This limited power of Attorney is restricted and limited to the matters specifically set forth herein and for the term beginning this day and continuing until canceled. Sign & Insert date below
*
Owner/Authorized signature
Date
*
-
Month
-
Day
Year
Date
Company Name
*
Company Name here
You understand and agree to the "Power of Attorney"?
*
Yes
No
I certify that I am the owner or legally Authorized to sign on behalf of the above Company
*
Owner/Authorized Signature
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I fully understand that this entire application is for a Federal and/or State filing and all information is true and correct.
*
Owner/Authorized signature
Submit
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