Tdf 1 Form – Fill Out and Use This PDF

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			USDOT NO.	________________
	OFFICIAL USE ONLY
	Amount Received_______________________		PIN	________________
	Processed By ____ Date Processed _________		SUB NO.	________________
			TDF 1(09-15)
	APPLICATION FOR INTRASTATE MOTOR CARRIER LICENSE
1. USDOT Number______________________________			FEIN/SSN_____________________________________________

Applicant _____________________________________________________________________________________________________________

Doing business as (trade name if any) ______________________________________________________________________________________

3. Type of Applicant ❏ SOLE PROPRIETORSHIP ❏ CORPORATION ❏ PARTNERSHIP ❏ OTHER

4. Principal Place of Business State (PPB) _____________________________________________________________________________________

Is Applicant properly registered with the Oklahoma Secretary of State?					❏ YES ❏ NO
If PPB State is not Oklahoma, provide:
Proposed/Actual Major Oklahoma Terminal or Home Office					Oklahoma Process Agent
Street __________________________________________________					Name _________________________________________________
City, State, Zip ___________________________________________					Street __________________________________________________
					City, State, Zip ___________________________________________
5. Type of Proposed Operations		❏ FOR HIRE	❏ PRIVATE
	(Check all that apply.)				(Check all that apply.)
	For Hire Carrier				Private Carrier
PROPERTY (Not Deleterious, Hazardous or Passengers)					PROPERTY (Not Deleterious, Hazardous or Passengers)
❏Restricted	❏Unrestricted	❏10,001 GVWR or under			❏Property
DELETERIOUS					DELETERIOUS
❏Deleterious Substances (also requires TDF 14)					❏Deleterious Substances (also requires TDF 14)
HAZARDOUS MATERIALS (may also require Haz Waste application)					HAZARDOUS MATERIALS (may also require Haz Waste application)
❏Hazardous Materials $1 million		❏Hazardous Materials $5 million			❏Hazardous Materials $1 million ❏Hazardous Materials $5 million
PASSENGERS (Vehicle Seating Capacity)
❏6 passengers or less		❏7 to 9 passengers
❏10 to 15 passengers		❏16 passengers or more

6. Does the applicant conduct interstate operations (across state lines)? ❏YES ❏NO Is the applicant registered in the UCR program? ❏YES ❏NO

7. Does the applicant intend to operate vehicles with a GVWR, GCWR, loaded weight or registered weight over 26,000 pounds? ❏YES or ❏NO

8. Quantity of Identification Devices. Stamps ______________________

9. Rule Book Serial No. ____________________________

The Applicant hereby declares that it has knowledge of and understands the rules of the Oklahoma Corporation Commission governing transportation by motor carriers and private carriers; that said rules and regulations will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for; and that under penalty of perjury, all statements and representations appearing in the foregoing application and all addendums are based upon my knowledge of the matters referred to and are true and correct.

Applicant’s Signature _______________________________________________________________________________________________________

Applicant’s Title __________________________________________________________________________________________________________

Attorney’s Signature (if any) _________________________________________________________________________________________________

OKLAHOMA CORPORATION COMMISSION
TRANSPORTATION DIVISION
P.O. BOX 52000	OKLAHOMA CITY, OK 73152-2000
JIM THORPE OFFICE BUILDING	2101 N. LINCOLN BLVD. ROOM 312		73105-4904
TELEPHONE (405) 521-2251 FAX NO. (405) 521-2916		INTERNET ADDRESS	http://www.occeweb.com

OAC 165:30-3-1; OAC 165:30-15-4

Please keep a copy of this completed application in your office. In the event we have any questions about your application and contact you, it will be helpful as a reference tool. Please make your check or money order payable to the Oklahoma Corporation Commission. All fees may be remitted in one check / money order. The application must be signed. ORIGINAL APPLICATION MUST BE FILED WITH ALL ATTACHMENTS. Application must be submitted with $100 filing fee plus additional fees as shown below. Please print or type application.

1.Applicant must be a legal entity (individual, corporation, partnership, etc.). A DBA (doing business as) may be indicated, but application cannot be filed in a trade name only. If a partnership, the Applicant must reflect the names of each of the partners. The Applicant’s USDOT number must be listed on this application. If the USDOT number is not yet issued, a copy of the completed MCS-150 mailed to FMCSA must be attached. An Applicant operating solely intrastate must apply for an intrastate USDOT number at https//www.fmcsa.dot.gov. The Applicant’s FEIN or individual’s SSN must be listed.

2.Mailing Address 1 is the location to which all correspondence is to be mailed. Permit service, attorney’s office, carrier’s address, or other location may be listed. If the address listed in Mailing Address 1 is NOT the carrier’s address, the carrier’s address MUST be listed in the Mailing Address 2 column. Carrier’s Physical Address or Location is the carrier’s actual physical location. If you have an out-of-state address, do not provide

Domicile County.

3.For Type of Applicant, choose your organization type.

4.If your organization is other than a Sole Proprietorship and your principal place of business is Oklahoma, you must be properly filed with the Oklahoma Secretary of State’s office (405) 521-3911 and a copy of the certificate of incorporation or similar paper must be submitted with this application. If your organization is other than a Sole Proprietorship and your principal place of business is other than Oklahoma, you must provide the address of your proposed or actual major Oklahoma terminal or home office along with either name and address of your Oklahoma Process Agent or a copy of your BOC-3 Process Agent Listing.

5.In the Type of Proposed Operations section, please check all that apply. Minimum liability insurance limits are based upon your type of operations. See “Liability Insurance” below. If more than one category is marked, the highest liability insurance limit is required.

6.If you operate a commercial motor vehicle transporting interstate (across state lines) shipments, you are subject to the Unified Carrier Registration Program. A “commercial motor vehicle” is defined as a self-propelled vehicle used on the highway in interstate commerce principally to transport passengers or cargo, if the vehicle: (a) has a gross vehicle weight rating or gross vehicle weight of 10,001pounds or more; (b) is designed to transport 10 or more passengers (including the driver); or (c) is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U.S.C. Section 5103 and transported in a quantity requiring placarding under regulations prescribed by the U.S. Secretary of Transportation.

7.If you intend to operate vehicles with a gross vehicle weight rating (GVWR) as specified by the manufacturer, gross combination weight rating (GCWR), loaded weight or registered weight thereof over 26,000 pounds; or placarded amounts of hazardous materials, you will be subject to federal safety regulations, even if your vehicles are solely intrastate.

8.If you intend to transport 15 or more passengers, you will be subject to federal safety regulations, even if your vehicles are solely intrastate.

9.Please list the number of identification devices (stamps) you wish to request. One device is required for each vehicle. Please remit $7.00 for each identification device. Additional identification devices may be ordered throughout the year using application TDF 16 or a written letter.

10.If you have the rule book in your possession, you must list its serial number. Every intrastate motor carrier must possess a current OCC Chapter 30 rule book. Rule books are available at a cost of $10 per rule book or you may download the document from our website. If you purchase a rule book, notices of rule changes will be provided to you.

11.Acceptable signatures on this application are as follows: (1) Sole proprietorship - sole proprietor; (2) Partnership - one of the partners; (3) Corporation - one of the officers or directors; (4) Limited liability company - the manager. An attorney or agent may sign in lieu of the applicant, but a copy of the power of attorney must be attached to the application.

Liability Insurance - An insurance filing (typically a Form E) must be filed with this office as proof of liability insurance. The name, address and liability limits must EXACTLY match the information shown on the front of this application. You may need to contact your insurance agent to inform the insurance company to provide the insurance filing to this office. (Agents do not typically provide the required filing.) Liability insurance requirements are combined single limits as follows:

Property (for hire)

O Unrestricted - $750,000

O Restricted (Sand, rock, gravel, asphaltic mixtures and similar road building materials; Unprocessed forestry products; Unprocessed agricultural commodities; Ordinary livestock) - $350,000

O Under 10,000 pounds GVWR - $300,000

Property (private carrier) - $350,000

Deleterious substances (non hazardous) - $750,000:

Passenger Carrier - utilizing vehicles having a seating capacity of 6 passengers or less - $100,000; 7 to 9 passengers - $750,000; 10 to 15 passengers - $1,000,000; 16 or more passengers - $5,000,000. Seating capacity includes the driver.

Hazardous materials as defined in and as required by OAC 165:30-3-11 and 49 CFR Part 387.

TDF 1

ATTACHMENT "A"

PART 1 LEGAL ENTITY INFORMATION (other than an individual/sole proprietorship)

Date of Incorporation ________________________

State of Incorporation________________________________

Attach copy of document/cover page filed with the Secretary of State or Partnership agreement.

PART 2 OPERATIONAL INFORMATION

Mark the type of commodities anticipated to be most generally transported. Check all that apply.

PART 3 HAZARDOUS MATERIALS

If you left all Hazardous Materials options blank in question 5 of the application itself, you may skip this section.

If you answer “No” to questions 2 and 3 of the Safety Summary Report, you may skip this section. (The Safety Summary Report is Part 5 of this Attachment A.)

Mark the Division/type of hazardous materials anticipated to be most generally transported - (Check all that apply.)

Note: Information on Poison Inhalation Hazards is found in column (7) of the hazardous materials table (49 CFR 172.101)

INTRA / INTER HAZARDOUS MATERIALS CARRIERS/SHIPPERS – IS YOUR COMPANY REGISTERED WITH RSPA?

Please refer to 49 CFR, Part 107.601 regarding the applicability of registration of persons who offer or transport hazardous materials. If your company meets the criteria listed, call Research and Special Programs Administration (RSPA) of the Federal Highway Administration at (202) 366-4109 for the appropriate application forms or download from https://hazmatonline.phmsa.dot.gov/services/.