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OMB No. 2126-0013

	U.S. Department of Transportation	Combined Motor Carrier Identification Report and HM Permit Application
	Federal Motor Carrier
	Federal Motor Carrier
	Safety Administration
REASON FOR FILING (Check Only One)

NEW APPLICATION

BIENNIAL UPDATE OR CHANGES

OUT OF BUSINESS NOTIFICATION

REAPPLICATION (AFTER REVOCATION OF NEW ENTRANT)

1. NAME OF MOTOR CARRIER

2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME

3. PRINCIPAL STREET ADDRESS/ROUTE NUMBER

4. CITY

5. MAILING ADDRESS (P O BOX)

6. MAILING CITY

7. STATE/PROVINCE

8. ZIP CODE+4

9. COLONIA (MEXICO ONLY)

10. STATE/PROVINCE

11. ZIP CODE+4

12. COLONIA (MEXICO ONLY)

13. PRINCIPAL BUSINESS PHONE NUMBER

14. PRINCIPAL CONTACT CELLULAR PHONE NUMBER

15. PRINCIPAL BUSINESS FAX NUMBER

16. USDOT NO.

17. MC OR MX NO.

18. DUN & BRADSTREET NO.

19. IRS/TAX ID NO.

EIN#SSN#

20. INTERNET E-MAIL ADDRESS

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

F. LOGS, POLES

J. FRESH PRODUCE

P. GRAIN, FEED, HAY

V. COMMODITIES DRY BULK

B. HOUSEHOLD GOODS

BEAMS, LUMBER

K. LIQUIDS/GASES

Q. COAL/COKE

W. REFRIGERATED FOOD

C. METAL; SHEETS;

G. BUILDING MATERIALS

L. INTERMODAL CONT.

R. MEAT

X. BEVERAGES

BB. CONSTRUCTION

COILS; ROLLS

H. MOBILE HOMES

M. PASSENGERS

S. GARBAGE, REFUSE, TRASH

Y. PAPER PRODUCTS

CC. WATER WELL

D. MOTOR VEHICLES

I. MACHINERY,

N. OIL FIELD EQUIPMENT

T. U.S. MAIL

Z. UTILITY

DD. OTHER

E. DRIVE AWAY/TOWAWAY

LARGE OBJECTS

O. LIVESTOCK

U. CHEMICALS

AA. FARM SUPPLIES

25. HAZARDOUS MATERIALS CARRIED OR SHIPPED (Circle All that Apply)

C – CARRIED

S – SHIPPED

B(BULK) – IN CARGO TANKS

NB(NON-BULK) – IN PACKAGES

A. DIV 1.1

K. DIV 2.2A (Ammonia) B

DIV 4.2

EE. HRCQ

B. DIV 1.2

L. DIV 2.3A

DIV 4.3

FF. CLASS 8

C. DIV 1.3

M. DIV 2.3B

DIV 5.1

GG. CLASS 8A

D. DIV 1.4

N. DIV 2.3C

DIV 5.2

HH. CLASS 8B

E. DIV 1.5

O. DIV 2.3D

DIV 6.2

II.

CLASS 9

F. DIV 1.6

P. Class 3

DIV 6.1A

JJ.

ELEVATED TEMP MAT. B

G. DIV 2.1

Q. Class 3A

AA. DIV 6.1B

KK. INFECTIOUS WASTE

S H. DIV 2.1 LPG

R. Class 3B

BB. DIV 6.1 Poison B

LL. MARINE POLLUTANTS

I. DIV 2.1(Methane) B

S. COMB LIQ

CC. DIV 6.1 SOLID B

MM. HAZARDOUS SUB (RQ) B

J. DIV 2.2

T. DIV 4.1

DD. CLASS 7

NN. HAZARDOUS WASTE

OO. ORM

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

School Bus

Mini-bus

Van

Limousine

Straight

Truck

Trailers

Hazmat Cargo

Motor

Trucks

Tractors

Tank Trucks

Tank Trailers

Coach

Number of vehicles carrying number of passengers (including the driver) below

1-8

9-15

16+

1-8

9-15

1-8

9-15

16+

OWNED

TERM LEASED

TRIP LEASED

27. DRIVER INFORMATION

INTERSTATE

INTRASTATE

TOTAL DRIVERS

TOTAL CDL DRIVERS

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. ___________________________________________________________

(Please print Name)

Form MCS-150B (Rev. 03-24-2005)

Expiration Date: 07/31/2007

OMB No. 2126-0013

30. WHICH OF THE FOLLOWING HAZARDOUS MATERIAL(S) DOES YOUR COMPANY TRANSPORT, CHECK ALL THAT APPLY:

□

Highway Route Controlled Quantities (HRCQ) of Radioactive materials.

More than 25 kg (55 pounds) of a Division 1.1, 1.2, or 1.3 material or a quantity of Division 1.5 material that requires placarding

For materials that meet the definition of “material poisonous by inhalation” (TIH) as defined in 49 CFR 171.8: More than 1 liter (1.08 quarts) per package of a material meeting the definition of a Hazard Zone A TIH material, a material meeting the definition of a Hazard Zone B TIH material in a bulk package (capacity greater than 450 liters [119 gallons]), or a material meeting the definition of a Hazard Zone C or D TIH material in a bulk packaging that has a capacity greater than 13,248 L (3,500 gallons).

□Shipments of compressed or refrigerated liquid methane or liquefied natural gas with a methane content of at least 85% in a bulk packaging that has a capacity greater than 13,248 L (3,500 gallons)

31.IF YOU CHECK QUESTION 30, ARE YOU APPLYING FOR OR RENEWING A HM SAFETY PERMIT? PLEASE CHECK ONE:

□ INITIAL

□ RENEWAL

32.IF YOUR COMPANY DOES NOT HAVE A U.S. DOT NUMBER, HOW MANY ACCIDENTS AS DEFINED IN 49 CFR 390.5 HAS YOUR COMPANY HAD IN THE PAST 365 DAYS?

_____________________________________________________________________________________________________________________________________________

33. DOES YOUR COMPANY CERTIFY THEY HAVE A SATISFACTORY SECURITY PROGRAM IN PLACE AS REQUIRED IN 49 CFR PART									□ Yes	□ No
385, SUBPART E?									□ Yes	□ No

34. IS YOUR COMPANY REQUIRED BY ANY STATE(S) TO HAVE A PERMIT FOR ANY OF THE HAZARDOUS MATERIALS LISTED									□ Yes	□ No
IN QUESTION 30?									□ Yes	□ No

35. IF YOUR ANSWER TO QUESTION 34 IS YES, CHECK THE STATE(S) IN WHICH YOU HAVE THE PERMIT.
□ AL	□ AK	□ AR	□ AZ	□ CA	□ CO	□ CT	□ DC	□ DE	□ FL	□ GA
□ HI	□ ID	□ IL	□ IN	□ IA	□ KS	□ KY	□ LA	□ MA	□ MD	□ ME
□ MI	□ MN	□ MO	□ MS	□ MT	□ NC	□ ND	□ NE	□ NH	□ NJ	□ NM
□ NV	□ NY	□ OH	□ OK	□ OR	□ PA	□ PR	□ RI	□ SC	□ SD	□ TN
□ TX	□ UT	□ VT	□ VA	□ WA	□ WV	□ WI	□ WY

NOTE:

All motor carriers must comply with all pertinent Federal, State, local and tribal statutory and regulatory requirements when operating within the United States. Such requirements include, but are not limited to, all applicable statutory and regulatory requirements administered by the U.S. Department of Labor, or by a State agency operating a plan pursuant to Section 18 of the Occupational Safety and Health Act of 1970 (“OSHA State plan agency”). Such requirements also include all applicable statutory and regulatory environmental standards and requirements administered by the U.S. Environmental Protection Agency or a State, local or tribal environmental protection agency. Compliance with these statutory and regulatory requirements may require motor carriers and/or individual operators to produce documents for review and inspection for the purpose of determining compliance with such statutes and regulations.

36. 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 Hazardous Materials Regulations. Under

(Please print Name)	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 ____________________________________________

Form MCS-150B (Rev. 03-24-2005)

Expiration Date: 07/31/2007

Question	Answer
Form Name	Form Mcs 150B
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	MCS-150B, TIH, COLONIA, OMB

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