Form Mcs 150 Ny – Fill Out and Use This PDF

Form MCS-150 NY (09/07)

**** You must answer question 17 in order to process this form ****

1. NAME OF MOTOR CARRIER					2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME
3. PRINCIPAL STREET ADDRESS					4. MAILING ADDRESS (P.O. BOX)
5. CITY		6. STATE/PROVINCE	7. ZIP CODE+4		8. MAILING CITY			9. STATE/PROVINCE			10. ZIP CODE+4
11. PRINCIPAL BUSINESS PHONE NUMBER					12. PRINCIPAL BUSINESS					13. NYSDOT Case Number
					FAX NUMBER					T-
14. USDOT #		15. MC OR MX #		16. DUN & BRADSTREET #			17. IRS/TAX ID #
							EIN#			SSN#
18. INTERNET E-MAIL ADDRESS					19. MOBILE NUMBER (with area code)

20.LIST CARRIER’S REPRESENTATIVE, ADDRESS AND TELEPHONE NUMBER

21.COMPANY OPERATION (Circle all that apply)

A. Interstate Carrier	B. Intrastate Hazmat Carrier	C. Intrastate Non-Hazmat Carrier		D. Interstate Shipper
E. Intrastate Shipper	F. Vehicle Registrant Only
22. CARRIER MILEAGE	(to nearest 10,000 miles for last calendar year)		Year
23. OPERATION CLASSIFICATION (Circle All that Apply)
A. Authorized For-Hire	D. Private Passengers (Business)		G. U.S. Mail		J. Local Government
B. Exempt For-Hire	E. Private Passengers (Non-Business)		H. Federal Government		K. Indian Tribe
C. Private Property	F. Migrant		I. State Government		L. Other _________________

24. CARGO CLASSIFICATIONS (Circle All that Apply)

A. GENERAL FREIGHT	G. BUILDING MATERIALS	M. PASSENGERS	S. GARBAGE, REFUSE, TRASH	Y. PAPER PRODUCTS
B. HOUSEHOLD GOODS	H. MOBILE HOMES	N. OIL FIELD EQUIPMENT	T. U.S. MAIL	Z. UTILITY
C. METAL: SHEETS, COILS,	I. MACHINERY, LARGE	O. LIVESTOCK	U. CHEMICALS	AA. FARM SUPPLIES
ROLLS	OBJECTS
D. MOTOR VEHICLES	J. FRESH PRODUCE	P. GRAIN, FEED, HAY	V. COMMODITIES DRY BULK	BB. CONSTRUCTION
E. DRIVE AWAY/TOWAWAY	K. LIQUIDS/GASES	Q. COAL/COKE	W. REFRIGERATED FOOD	CC. WATER WELL
F. LOGS, POLES, BEAMS,	L. INTERMODAL CONT.	R. MEAT	X. BEVERAGES	DD. OTHER _________
LUMBER

Page 1

25. HAZARDOUS MATERIALS CARRIED OR SHIPPED (Circle All that Apply) C - CARRIED S - SHIPPED B (BULK) - IN CARGO TANKS NB(NON-BULK) - IN PACKAGES

C S OO. ORM

B NB

26. NUMBER OF VEHICLES THAT CAN BE OPERATED IN THE U.S.

OWNED

TERM LEASED

TRIP LEASED

Within 100-Mile Radius

Beyond 100-Mile Radius

28. IS YOUR U.S. DOT NUMBER REGISTRATION CURRENTLY REVOKED BY THE FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION? Yes ____ No ___

If Yes, enter your U.S. DOT Number __________________________________________________

29.PLEASE ENTER NAME(S) OF SOLE PROPRIETOR)S), OFFICERS OR PARTNERS AND TITLES (E.G. PRESIDENT, TREASURER, GENERAL PARTNER, LIMITED PARTNER)

1.______________________________________________________ 2.__________________________________________________

30.CERTIFICATION STATEMENT (to be completed by an authorized official)

I, ___________________________________, certify that I am familiar with the Federal Motor Carrier Safety Regulations and/or the Federal

(Please print Name)	Hazardous Materials Regulations. Under penalties of perjury. I declare that the information entered
	on this report is, to the best of my knowledge and belief, true, correct, and complete.
Signature _________________________________________		Date __________________	Title ___________________________________

Mail to:

New York State Department of Transportation

Office of Modal Safety & Security

Administration & Data Management Section

50 Wolf Road, POD 53

Albany, NY 12232-0879

Form MCS-150 NY (09/07)	Page 2

INSTRUCTIONS FOR COMPLETING THE MOTOR CARRIER IDENTIFICATION REPORT (MCS-150NY)

(Please Print or Type All Information)

1.Enter the legal name of the business entity (i.e., individual, partnership, corporation or limited liability company) that owns/controls the motor carrier. If the business entity is an individual or partnership with a doing business as (d/b/a) or trade name, attach one copy of the business certificate issued by the County Clerk’s Office. If the business entity is a corporation, limited liability company (LLC) or limited partnership (LP), attach a copy of the filing receipt issued by the New York Secretary of State.

2.If the business entity is operating under a name other than that in Block 1, (i.e., d/b/a or trade name) enter that name. Otherwise, leave blank.

3.Enter the principal place of business, street address, where safety records are kept.

4.Enter mailing address if different from the physical address, otherwise leave blank. Also, applies to #8, #9, & #10.

5.Enter the city where the principal place of business is located.

6.Enter the two-letter postal abbreviation for the State or the name of the Canadian Province corresponding with the physical address.

7.Enter the zip code + 4 number corresponding with the physical street address.

8.Enter the city corresponding with the mailing address.

9.Enter the two-letter postal abbreviation for the State or the name of the Canadian Province corresponding with the mailing address.

10.Enter the zip code + 4 number corresponding with the mailing address

11.Enter the telephone number, including area code, of the principal place of business.

12.Enter the Fax number, including area code, of the principal place of business.

13.Enter the case number (T-number) assigned to the motor carrier for intrastate for-hire operations in New York if already assigned.

14.If the company is not a new applicant, that is, if it already has a USDOT number, enter the company’s USDOT number.

15.If the company has already been assigned an “MC” or “MX” identification number for Interstate FMCSA operating authority, enter the number.

16.Enter your Dun & Bradstreet business number (used as a secondary identifier; if you do not have one, leave blank).

17.Enter either the employer identification number (EIN #) or social security number (SSN #) assigned to the motor carrier operation by the Internal Revenue Service.

18.Enter the e-mail address for the official point of contact, if you have one.

19.Enter the mobile number, including area code, of the business.

20.Enter the name, address, and telephone number of the Motor Carrier’s representative. If there is none, enter N/A.

21.Circle the appropriate type of carrier operation classification.

o Interstate (Carrier/Shipper) -- transportation of persons or property across State Lines, including international boundaries, or wholly within one State as part of a thorough movement that originates or terminates in another State or country.

o Intrastate (Hazmat Carrier, Non-Hazmat Carrier, Shipper) - transportation of property wholly within the boundaries of a single State.

o Vehicle Registrant Only - The company is a Vehicle Registrant Only if its base state of operations requires the company/individual to obtain a USDOT Number as a required part of its state commercial vehicle registration process AND the individual that is listed on the vehicle registration and to whom license plates are issued will never operate the CMV under its own assigned USDOT Number or Operating Authority. Two of the more common reasons to receive a USDOT Number with a “vehicle registrant only” status are illustrated in the examples below. If you select “vehicle registrant only” as the response, do not select any other responses for item 21.

Examples:

o The company owns and registers its commercial trucks for the sole purpose of renting or leasing those trucks to Motor Carriers that will operate the trucks to transport goods.

o The company is an owner-operator that will never operate the trucks under its own USDOT Number or Operating Authority (the company only operates under another company’s USDOT Number or Operating Authority).

NOTE: If the company is a Vehicle Registrant Only, do not select additional company operations. Skip to item 30, sign, and date the form.

22.Enter the total mileage of all commercial motor vehicles in the company’s operation to nearest 10,000 miles for the last calendar year.

23.Circle appropriate classification. Circle all that apply. If “L. Other” is circled, enter the type of operation in the space provided.

Authorized For Hire—transportation for compensation as a common or contract carrier of property, owned by others, or passengers under the provisions of the FMCSA.

Exempt For Hire—transportation for compensation of property or passengers exempt from the economic regulation by the FMCSA.

Private Property—means a person who provides transportation of property by commercial motor vehicle and is not a for-hire motor carrier. Private Passengers (Business)—a private motor carrier engaged in the interstate transportation of passengers which is provided in the furtherance of a commercial enterprise and is not available to the public at large (e.g., bands).

Private Passengers (Non-Business)—a private motor carrier involved in the interstate transportation of passengers that does not otherwise meet the definition of a private motor carrier of passengers (business) (e.g., church buses).

Migrant—interstate transportation, including a contract carrier, but not a common carrier of 3 or more migrant workers to or from their employment by any motor vehicle other than a passenger automobile or station wagon.

U.S. Mail—transportation of U.S. Mail under contract with the U.S. Postal Service.

Federal Government—transportation of property or passengers by a U.S. Federal Government agency. State Government—transportation of property or passengers by a U.S. State Government agency. Local Government—transportation of property or passengers by a local municipality.

Indian Tribe—transportation of property or passengers by an Indian tribal government.

Other—transportation of property or passengers by an operation classification not described above.

24.Circle all the letters of the types of cargo you usually transport. If household goods is circled and you do not have authority from this Department to operate as an intrastate motor carrier of household goods, you must file form RA51 before beginning operations. This form is available at https://www.nysdot.gov/portal/page/portal/divisions/operating/osss/truck/registration-licensing#household or by calling 518-457-6503. If “Other” is circled, enter the name of the commodity in the space provided.

Form MCS-150 NY (09/07)

Page 3

25.Circle all types of hazardous materials (HM) you transport/ship. In the columns before the HM types, circle C for a carrier of HM and S for a shipper of HM. In the columns following the HM types, circle B if the HM is transported in bulk (over 119 gallons) and NB if the HM is transported in non-bulk

(119 gallons or less). The HM types correspond to the classes and divisions listed in 49 CFR 173.2. Below are clarifications for the lettered codes:

Note: Information on Poison Inhalation Hazards is found in column 7 of the Hazardous Materials table, (49 CFR 172.101).

26.Enter the total number of vehicles owned, term leased and trip leased, that are, or can be, operational the day this form is completed.Passenger vehicles are defined as:

Motor coach—a vehicle designed for long distance transportation of passengers, usually equipped with storage racks above the seats and a baggage hold beneath the passenger compartment.

School Bus—a vehicle designed and/or equipped mainly to carry primary and secondary students to and from school, usually built on a medium or large truck chassis.

Passenger Van—A small motor vehicle designed or used to transport 15 or fewer passengers, including the driver.

Mini-bus-A motor behicle designed or used to transport 16 or more passengers, including the driver, and typically built on a small truck chassis; has a smaller searing capacity than a motor coach.

Limousine—A passenger vehicle usually built on a lengthened automobile chassis.

27.Enter the number of interstate/intrastate drivers used on an average work day. Part-time, casual, term leased, trip leased and company drivers are to be included. Also, enter the total number of drivers (Interstate/Intrastate) and the total number of drivers who have a Commercial Drivers License (CDL).

Interstate—driver transports people or property across State lines, including international boundaries, or wholly within one State as part of a through movement that originates or terminates in another State or country.

Intrastate—driver transports people or property wholly within one State.

100-mile radius driver—driver operates only within a 100 air-mile radius of the normal work reporting location.

28.Enter US DOT Number if your US DOT Number registration revoked by the Federal Motor Carrier Safety Administration (FMCSA).

29.Enter name(s) of sole proprietor(s), officers, or partners and their titles -- If the company’s legal business structure is “Sole Prioprietor,” then enter the owner’s name and title in the spaces provided; otherwise, enter the name of two company partners (if the company is a partnership) or two corporate officers and their titles if the company is a corporation (for example, corporate officers might include Vice President, Secretary, Treasurer, President).

30.Print or type the name, in the space provided, of the individual authorized to sign documents on behalf of the entity listed in Block 1. That individual must sign, date, and show his or her title in the spaces provided (Certification Statement, see 49 CFR 390.19).

Form MCS-150 NY (09/07)

Page 4