Form MCSA – 5889 – Section A

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Today's Date

Requestor's Fax Number

(Include Area Code)

Requestor's E-Mail

If any

MOTOR CARRIER IDENTIFICATION INFORMATION:

Current Legal Name

(Personal, partnership, or corporation)

First Middle Last

Current "Doing business as name"

(If different from legal name)

Docket | MC Number

US DOT Number

MX Number

MX Only

RFC Number

MX Only

FF Number

(Freight Forwarders ONLY)

ADDRESSES (As currently listed in FMCSA systems)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

(Include Area Code)

Phone Numbers

Current Business Number

(Include Area Code)

Current Cell Phone Number

(Include Area Code)

AFFILIATION WITH FMCSA-LICENSED ENTITIES OR OTHER APPLICANTS APPLYING FOR USDOT NUMBER REGISTRATION

Do you currently have, or have you had within the last three years of the date of this application, relationships involving common stock, common ownership, common management, common control or familial relationships with any FMCSA-regulated entities?

Yes

I verify under penalty of perjury, under the laws of the United States of America, that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under 18 U.S.C. § 1001 by imprisonment of up to 5 years and fines up to $250,000 for each offense. Additionally these statements are punishable as perjury under 18 U.S.C. § 1621, which provides for fines of up to $250,000 or imprisonment of up to 5 years for each offense. I further certify under penalty of perjury, 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, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, formerly Pub. L. 100-690, Title V, Section 5301, Nov. 18, 1988, 102 Stat. 4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002 (d), Nov. 29, 1990, 104 Stat. 4827 (21 U.S.C. 862).

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Applicant Title

Signature

Form MCSA - 5889 - Section A*

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Credit Card

Cardholder Name

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