Co 1 Form – Fill Out and Use This PDF

Illinois Commerce Commission 527 East Capitol Avenue, Springfield, Illinois 62701 Phone (217) 782-4654

2017 Intrastate Cab Card Order Form

IMPORTANT NOTICE – PLEASE READ

2017 cab cards will NOT be mailed via US Mail. You must provide an Email address in the field below in order to receive the purchased 2017 cab cards electronically.

Full Legal Name of Motor Carrier:			ILCC Number:
Trade Name:			Email:
Business Address:			Business Phone Number:
City:			State:	Zip Code:
2017 Intrastate Cab Cards	Quantity		Unit Cost		Total
Multiply quantity by unit cost to determine total due.		$5.00

PLEASE NOTE: 2017 Intrastate Cab Cards expire on December 31, 2017.

I, the undersigned, under penalty for false statement, certify that the above information is true and accurate and that I am authorized to execute and file this document on behalf of the licensed motor carrier.

INSTRUCTIONS

1.All fields located on this form must be completed.

2.The ILCC Number is the number issued to the motor carrier by the Illinois Commerce Commission. DO NOT LIST USDOT Numbers or MC Numbers issued by the federal agency, Federal Motor Carrier Safety Administration (FMCSA), in the ILCC Number field.

3.For corporations, LLCs, LPs, LLPs and LLLPs, the legal name must be entered exactly as it is registered with the Illinois Secretary of State. For general partnerships, the legal name must be entered exactly as it appears on the written partnership agreement.

4.For sole proprietor or general partnership, the trade name, if any, must be entered exactly as it is registered with the County Clerk’s office responsible for regulating trade or business names in your locality. For corporations, LLCs, LPs and LLLPs the trade name, if any, must be entered exactly as it is registered with the Illinois Secretary of State.

5.Submit the completed form and check or money order via US Mail to the following address. Make checks payable to Illinois Commerce Commission/TRF. Please note that FAXED, EMAILED OR OVER-THE-PHONE ORDERS ARE NOT ACCEPTED. If you attempt to submit the order form with payment via fax, email or telephone, the order will NOT be

processed.

Illinois Commerce Commission ATTN: Processing and Information 527 East Capitol Avenue Springfield, Illinois 62701

6.Receipt of Cab Cards: 2017 cab cards will not be mailed via US Mail. You must provide an Email address in the field above in order to receive the 2017 cab cards electronically.

ILCC OFFICE USE ONLY

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