Form OCE-46 Request for Revocation of Authority Granted

OMB NO: 2126-0018 EXPIRATION DATE:
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act
unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0018. Public reporting for this collection of information is estimated to be approximately 15
minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-MMI, Washington, D.C. 20590.

U. S. Department of Transportation
Federal Motor Carrier
Safety Administration

DEPARTMENT OF TRANSPORTATION
FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION
REQUEST FOR REVOCATION OF REGISTRATION
Docket No.________________________________________

Name of carrier, freight forwarder, or broker making request
______________________________________________________________________________________________
Address, City, State, Zip Code of requesting carrier
For the reasons stated below, this carrier, freight forwarder, or broker, which is the holder of the aboveidentified permit(s), certificate(s), or license(s), hereby requests revocation of such registration to the extent specified,
in accordance with the provisions of 49 U.S.C. 13905.
Reason for request for revocation:
_______________________________________________________________________________________________
It is clearly understood that upon revocation of this registration, operations that are revoked may not be
resumed unless this authority is reinstated or other registration has been issued.
_______________________________________________
Type/print name of person authorized to submit this request

________________________
Daytime Telephone Number

____________________________________________
Signature of person authorized to submit this request

______________________________
Date

Note: Signature must be notarized

OR signed in the presence of a FMCSA staff member.

Affix Notary Seal
OR

City/County:
State:
Subscribed and sworn to before me this_________

day of
________________________________________________
Signature of FMCSA Staff Member
Date
_________________________________
Title

, 20

My Commission Expires:__________________

FORM OCE-46
(06/07)

PLEASE RETURN YOUR REQUEST FOR REVOCATION OF AUTHORITY

FORM OCE-46

TO:

FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION
INSURANCE COMPLIANCE DIVISION
SUITE: 600

400 VIRGINIA AVE., SW

WASHINGTON, DC 20024

The attached Form OCE-46, Request for Revocation, must be completed (the docket number and the
complete name of the carrier) and notarized, in order that FMCSA may process your request. All
questions should be directed to the Insurance Compliance Division at (202) 385-2423.