Mcs 150Ct Form – Fill Out and Use This PDF

Read Instructions on following pages to help complete this application.

REASON FOR FILING (Mark only one)

1. NAME OF MOTOR CARRIER				2. TRADE OR D.B.A. (DOING BUSINESS AS) NAME
3. PRINCIPAL ADDRESS	4. CITY			5. STATE/PROVINCE		6. ZIP CODE+4	7. COLONIA (MEXICO ONLY)
8. MAILING ADDRESS	9. CITY			10. STATE/PROVINCE		11. ZIP CODE+4	12. COLONIA (MEXICO ONLY)
13. PRINCIPAL BUSINESS PHONE NUMBER			14. PRINCIPAL CONTACT CELL PHONE NUMBER		15. PRINCIPAL BUSINESS FAX NUMBER

22. COMPANY OPERATION (Mark all that apply) A.			Interstate Carrier	C.		Intrastate Non-Hazmat Carrier	E.		Intrastate Hazmat Shipper
B.			Intrastate Hazmat Carrier	D.		Interstate Hazmat Shipper

23. OPERATION CLASSIFICATION (Mark 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 (Mark all that apply)

A.

GENERAL FREIGHT

G.

BUILDING MATERIALS

M.

PASSENGERS

S.

GARBAGE, REFUSE, TRASH

Y.

PAPER PRODUCT

B.

HOUSEHOLD GOODS

H.

MOBILE HOMES

N.

OIL FIELD EQUIPMENT

T.

U.S. MAIL

Z.

UTILITY

C.

METAL:SHEETS, COILS, ROLLS

I.

MACHINERY, LARGE OBJECTS

O.

LIVESTOCK

U.

CHEMICALS

AA.

FARM SUPPLIES

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

X.

DD.

F.

LOGS, POLES, BEAMS, LUMBER

L.

INTERMODAL CONT.

R.

MEAT

BEVERAGES

OTHER

U.DIV 4.2

V.DIV 4.3

W.DIV 5.1

X.DIV 5.2

Y.DIV 6.2

Z.DIV 6.1A

AA.DIV 6.1B

BB.DIV 6.1 POISON

CC.DIV 6.1 SOLID

DD.CLASS 7

EE. HRCQ

FF. CLASS 8

GG. CLASS 8A

HH. CLASS 8B

II. CLASS 9

JJ.ELEVATED TEMP MAT.

KK.INFECTIOUS WASTE LL. MARINE POLLUTANTS

MM.HAZARDOUS SUB (RQ)

NN.HAZARDOUS WASTE

OO.ORM

26. NUMBER OF VEHICLES THAT WILL BE OPERATED IN CONNECTICUT

Number of vehicles carring number of passengers (including the driver)

Straight

Truck

Trailers

Hazmat Cargo

Hazmat Cargo

Motor-

School Bus

Mini Bus

Passenger Van

Limousine

Trucks

Tractors

Tank Trucks

Tank Trailers

coach

1-8

9-15

16+

16+

9-15

16+

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

29. PLEASE ENTER NAME(S) OF SOLE PROPRIETOR(S), OFFICERS OR PARTNERS AND TITLES (e.g. president, treasurer, general partner, limited partner)

1.	2.

Signature

Date

Title

(Please print)

INSTRUCTIONS FOR MOTOR CARRIER IDENTIFICATION FORM (MCS150CT)

These instructions have been adapted for motor carriers in commerce in Connecticut Only (intrastate). The unedited instructions may be found at www.fmcsa.dot.gov.

REASONS FOR FILING:

NEW APPLICATION - To obtain an intrastate USDOT number.

BIENNIAL UPDATE OR CHANGES - To file the formal MCS-150CT biennial update, or to update MCSl50CT information.

OUT OF BUSINESS NOTIFICATION - To notify the Department of Motor Vehicles, Commercial Vehicle Safety Division that the company is no longer operating as an intrastate motor carrier.

1.Name of Motor Carrier - This is the legal name of the business entity that owns/controls the motor carrier operation. The name entered here should be the full legal business name as filed with the Secretary of the State's Office.

2.Trade or D.B.A. (Doing Business As) Name - Enter the company's trade name if it is different from

the company's official business name.

3-6. Principal Address - Enter the Connecticut address where the company's safety records are maintained.

Skip 7.

8-11. Mailing Address - Enter the mailing address where the company wants all its correspondence to be sent (this may be a P.O. Box).

Skip 12.

13.Principal Business Phone Number - Enter the primary telephone number, including area code, for the "Principal Address" (items 3-6).

14.Principal Contact Cell Phone Number - Enter the cell phone number, if any, including area code.

15.Principal Business Fax Number - Enter the company's fax number, including area code.

16.USDOT NO. - If the company is not a new applicant, that is if it already has an intrastate USDOT number, enter the company's intrastate USDOT number.

17.MC OR MX NO. - If the company has already been assigned an "MC" or "MX" identification number for Interstate FMCSA Operating Authority, enter the number. This includes MC or MX numbers that are pending.

18.Dun & Bradstreet NO. - If the company has a Dun & Bradstreet identifier number, enter it.

19.IRS/TAX lD NO. - Enter either the Employer Identification Number (EIN) assigned to the motor carrier company by the Internal Revenue Service, or the owner's Social Security Number (SSN).

20.Internet E-Mail Address - Enter the e-mail address, if the company has one, for the official point of contact.

21.Carrier Mileage - Enter the total mileage of all motor vehicles in the company's intrastate operation to the nearest 10,000 miles for the last calendar year.

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22.Company Operation - Interstate Carrier - The company is an interstate carrier if any part of its operation transports property or passengers in support of interstate commerce, i.e., the property or passengers cross State lines either before the company received them, while the company is transporting them, or after the company has transferred the property or passengers. Intrastate Hazmat Carrier - The company is an intrastate hazardous materials carrier if any part of its business operation meets the following criteria: Transports hazardous materials in quantities that are regulated by the Department of Transportation (DOT) and never crosses State lines. The company is required to comply with FMCSA Safety Regulations and Hazardous Materials Regulations. Intrastate Non-Hazmat Carrier - The company is an intrastate non-hazardous materials carrier if its business operation meets the following criteria: Does NOT transport hazardous materials in quantities that are regulated by DOT and never crosses State lines. Interstate Hazmat Shipper - The company is an interstate hazardous materials shipper if any part of its business operation offers, or makes hazardous materials available to a carrier for transportation in interstate or foreign commerce. Intrastate Hazmat Shipper - The company is an intrastate hazardous materials shipper if it exclusively tenders or makes hazardous materials available to an intrastate hazmat carrier for actual transport. If the company offers or makes available hazardous materials AND transports hazardous materials, then it is considered as both an intrastate hazmat shipper and an interstate or intrastate motor carrier (both options should be selected in response to this item).

23.Operation Classification - Is based on the type of business the company is engaged in. A. Authorized For Hire - A non-exempt motor carrier who receives compensation for transporting passengers, FMCSA-regulated

goods, or household goods that are owned by others. B. Exempt For-Hire - A carrier who receives compensation for transporting only exempt goods (commodities that are NOT regulated by the FMCSA). Carriers are also exempt if they only transport employees of their company (e.g., a company shuttles its own employees to and from a work station). Exempt status typically excuses a carrier from the operating authority requirement, but an intrastate USDOT number is still required. C. Private Property - A company that transports its own cargo, usually as a pari of a business that produces, uses, sells, and/or buys the cargo that is being hauled. D. Private Passengers (Business) - A "for-profit" company that provides intrastate transportation of passengers in order to support its primary line of business. The passenger transportation service should not be available to the general public.

E. Private Passengers (Non-business) - A "not-for-profit" company that provides intrastate transportation of passengers in order to support its primary line of business. The passenger transportation service that is offered should not be available to the general public. F. Migrant - Intrastate transportation provided by a contract carrier, but not a common carrier, of three or more migrant workers to or from their employment using any motor vehicle other than a passenger automobile or station wagon. A contract carrier provides transport service to one or more companies on a contract basis. Contract carriers do not maintain a regularly scheduled service. A common carrier transports persons or property for pay to anyone at any time and to any place within its operating authority. G. U.S. Mail - Transportation of U.S. Mail under contract with the U.S. Postal Service. H. Federal Government Transportation of property or passengers by a U.S. Federal Government Agency. I. State Government Transportation

of property or passengers by a U.S. State Government Agency. J. Local Government Transportation of property or passengers by a local municipality. K. Indian Tribe - Transportation of property or passengers by an Indian tribal government. L. Other - Transportation of property or passengers by an operation classification not described above.

24.Cargo Classifications - Refers to the types of materials the company transports or ships (offers for transport),

The company may transport/ship materials from multiple categories. Select all the letters corresponding to the types of cargo the company transports/ships. If "Other" is selected, enter the name of the commodity in the space provided. NOTE: If you indicate that the company transports passengers, it means that the company uses a motor coach, school bus, mini-bus, van, or limousine to transport passengers. Do not select this item if someone rides along to assist the driver when the company's primary business is to transport property. If you check this option, you will also have to indicate the number of each type of passenger vehicle that is owned or leased under the motor coach, school bus, mini-bus, van, or limousine headings provided in item 26 of this form.

25.Hazardous Materials (Carrier or Shipper) - Complete this item only if the company transports or ships

(offers for transport) hazardous materials. Otherwise, proceed to item 26. The letters "c" and "s" in the columns

refer to "Carrier" and "Shipper." Select "c" or "s" next to the hazardous materials that the company carries or ships. If the company is both a carrier and a shipper of the hazardous materials, select both "c" and "S." The letters "B"

and "NB" refer to "Bulk" and "Non-bulk." Select "B" next to the appropriate hazardous materials if the company transports/ships greater than 119 gallons of it. If the company transports/ships 119 gallons or less of the hazardous materials, select "NB." The Hazardous Materials Classes and Divisions listed correspond to those listed in 49 CFR

173.2.The Hazardous Materials Classes and Divisions listed below correspond to those listed in 49 CFR 173.2. (Short descriptions are provided. For more information see the Hazardous Materials guide at http://www.fmcsa.dot.gov/hm-comply.) A. Div l.l Explosives (with mass explosion hazard) B. Div 1.2 Explosives (with projection hazard) C. Div 1.3 Explosives (with predominantly fire hazard) D. Div 1.4 Explosives

(with no significant blast hazard) E. Div 1.5 Explosives (Very insensitive explosives; blasting agents)

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F. Div 1.6 Explosives (Extremely insensitive detonating substances) G. Div 2.1 Flammable Gas H. Div 2.1 LPG (Liquefied Petroleum Gas) I. Div 2.1 Methane Gas J. Div 2.2 Non-Flammable Compressed Gas K. Div 2.2 D (Anhydrous Ammonia) L. Div 2.3 A (Poison Gas which is Poison Inhalation Hazard (PIH) Zone A) M. Div 2.3 B (Poison Gas which is PIH Zone B) N. Div 2.3 C (Poison Gas which is PIH Zone C) O. Div 2.3 D (Poison Gas which is PIH

Zone D) P. Class 3 Flammable and Combustible Liquid Q. Class 3 A (Flammable Liquid which is a PIH Zone A) R. Class 3 B (Flammable Liquid which is a PIH Zone B) S. Combustible Liquid (Refer to 49 CFR 173.20 (b)) T. Div 4.1 Flammable Solid U. Div 4.2 Spontaneously Combustible Material V. Div 4.3 Dangerous When Wet Material W. Div 5.1 Oxidizer X. Div 5.2 Organic Peroxide Y. Div 6.2 Infectious Substance (Etiologic agent) Z. Div 6.1 A (Poison Liquid which is a PIH Zone A) AA. Div 6.1 B (Poison Liquid which is a PIH Zone B) BB. Div

6.1Poison (Poisonous Liquid with no inhalation hazard) CC. Div 6.1 Solid (Meets the definition of a poisonous solid) DD. Class 7 Radioactive Materials EE. HRCQ (Highway Route Controlled Quantity of Radioactive Material) FF. Class 8 Corrosive Material GG. Class 8 A (Corrosive Liquid which is a PIH Zone A) HH. Class 8 B (Corrosive Liquid which is a PIH Zone B) II. Class 9 Miscellaneous Hazardous Materials (See http://www.fmcsa.dot.gov/hm-comply for more details) JJ. Elevated Temperature Material (Meets definition in 49 CFR 171.8 for an elevated temperature material) KK. Infectious Waste (Meets definition in 49 CFR 171.8 for an infectious waste) LL. Marine Pollutants (Meets Definition in 49 CFR 171.8 for a marine pollutant) MM. Hazardous Sub (RQ) (Meets definition in 49 CFR 171.8 of a reportable quantity of a hazardous substance) NN. Hazardous Waste (Meets definition in 49 CFR 171.8 ofa hazardous waste) OO. ORM (Meets definition in 49 CFR

171.8of Other Regulated Material).

26. Number of Vehicles That Will Be Operated In Connecticut - Provide the number of each type of motor

vehicle that the company uses in its operations broken out by the method used to acquire the vehicle (owned, term-leased or trip-leased)

27.Drivel' Information - Enter the total number of drivers used in the company's operations and the total number of drivers that hold a valid Commercial Driver's License (CDL).

28.If the company's intrastate USDOT Number and registration are currently revoked by FMCSA - Enter the company's assigned intrastate USDOT number in the space provided.

29.Enter name(s) of sole proprietor(s), officers, or partners and their titles - If the company's legal business structure is "Sole Proprietor," 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.

30.Certification Statement - Print or type the name of the individual authorized to sign documents on behalf of the entity listed in item I (Name of Motor Carrier). This individual must sign, date, and print or type his/her name and title in the spaces provided. The individual's signature must match his/her name. The authorized signer in this item should match one of the names provided in response to item 29.

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