Download:
pdf |
pdfOMB No.: 2126-0051
Expiration: 11/30/2016
United States Department of Transportation
Federal Motor Carrier Safety Administration
FMCSA Registration/Update(s)
(Application for USDOT Number/Operating Authority Registration)
INSTRUCTIONS for FORM MCSA-1
NOTE: Mexico-domiciled motor carriers that operate, or seek authority to operate, beyond
United States municipalities on the United States-Mexico border and their commercial
zones should not complete this form. They must complete Forms OP-1(MX) and MCS-150.
WHO MUST FILE
This form must be filed electronically by all for-hire motor carriers and private motor carriers operating commercial motor vehicles
(CMVs), brokers, freight forwarders, hazardous materials safety permit applicants, cargo tank facilities, and intermodal equipment
providers operating in interstate or foreign commerce. A new applicant must file the Form MCSA-1 before beginning operations. In
addition, all for-hire motor carriers, brokers and freight forwarders must file this form electronically to notify the Agency of a transfer
of operating authority registration and provide a copy of the operating authority registration being transferred. All supplemental
documents should be scanned and uploaded as appropriate. A transferee of operating authority registration must complete the
entire Form MCSA-1 to obtain a USDOT Number if it does not currently have one. All entities must use this form to update their
information as required.
The following entities must register using this form if they engage in interstate commerce as defined in 49 CFR 390.5:
• For-hire motor carriers of property and passengers domiciled in the United States, Canada, and outside of North America.
• For-hire Mexico-domiciled motor carriers of property and household goods and Mexico-domiciled private motor carriers that
seek to operate exclusively within U.S. municipalities on the United States-Mexico International Border and their commercial
zones. Under North American Free Trade Agreement (NAFTA) Annex I, page I-U-20, a Mexico-domiciled carrier may not provide
point-to-point transportation services, including express delivery services, within the United States for goods other than
international cargo.
• U.S.-based motor carriers owned or controlled by Mexican nationals transporting passengers and/or international cargo (goods
originating or terminating in a foreign country).
• Private motor carriers (except Mexico-domiciled private carriers operating beyond the border commercial zones).
• Property brokers of general freight and/or household goods.
• Freight forwarders of general freight and/or household goods.
• Intermodal equipment providers.
• Cargo Tank Facilities.
INSTRUCTIONS MCSA-1 [URS-1] Page 1 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
REASONS TO FILE
1. New registration—to register for the first time.
2. New entrant reapplication—to reapply after new entrant registration has been revoked.
3. Reinstatement—to restore inactive or revoked registration to good standing.
4. Biennial update—to file the update required every 24 months. An entity may also update its record with FMCSA at any time within
this 24-month period.
5. Name /address change/form of business—to file a change to a company’s name, address, or form of business.
6. Notification of transfers of operating authority registration (both transferee and transferor)
7. Other —to file other miscellaneous changes.
For each reason for filing, complete (or confirm the information in) the
appropriate sections of Form MCSA-1 as shown in the table on page 2 of the form.
HOW TO FILE
An applicant must complete Form MCSA-1 and any attachments or statements in English and submit the completed material to
FMCSA by filing online at the FMCSA Web site (www.fmcsa.dot.gov).
COST TO FILE
See Section O, titled “Filing Fee Information,” of the Form MCSA-1 application.
TELEPHONE ASSISTANCE
For additional assistance, or to obtain information regarding the status of an application, consult the FMCSA Web site (www.fmcsa.
dot.gov), call FMCSA Support Services at (800) 832-5660, or contact FMCSA Headquarters or State Division offices (See “Contacting
Us” on the FMCSA Web site).
Applicants should consult these instructions as they complete Form MCSA-1.
INSTRUCTIONS MCSA-1 [URS-1] Page 2 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
This section provides general information about the seven reasons for filing the form
MCSA-1. For the applicant’s convenience, line-by-line instructions begin on page 5.
AN OVERVIEW OF THE 7 REASONS FOR FILING FORM MCSA-1
1. New Registration
There is a $300 fee for this transaction.
Check the “New Registration” box if registering for the first time or if you are already registered as one type of entity and are seeking
to register as a different type of entity (e.g., motor carrier seeking new registration as a property broker).
In addition to completing this form, certain new applicants also must complete the additional requirements described below:
• Financial Responsibility: All for-hire motor carriers of property and passengers, property brokers, freight forwarders performing
transfer, collection and delivery services, and private carriers of hazardous materials also must demonstrate that they have in
effect the minimum amount of financial responsibility (49 CFR part 387). Applicants may not begin to operate until the required
evidence of financial responsibility has been electronically filed with, and approved by, FMCSA and an active USDOT Number has
been issued. (A USDOT Number becomes active only after process agent and applicable financial responsibility filings have been completed and approved by FMCSA, and/or any
protests by persons opposing an application for operating authority registration have been adjudicated.)
• Household Goods: New for-hire motor carriers of household goods and freight forwarders of household goods must comply
with the minimum cargo insurance requirements as provided in 49 CFR part 387. Operations may not begin until evidence of
compliance with the minimum cargo insurance requirements has been electronically filed with, and approved by, FMCSA and
an active USDOT Number has been issued. (A USDOT Number becomes active only after process agent and applicable financial responsibility filings have been
completed and approved by FMCSA, and/or any protests by persons opposing an application for operating authority registration have been adjudicated.)
• Designation of Agents for Service of Process: New applicants must electronically submit a signed and dated Form BOC-3 titled,
“Designation of Agents–Motor Carriers, Brokers and Freight Forwarders.” It must include the street addresses (not the post office
box number) of designated agents for service of legal process and administrative notices in connection with the enforcement of
applicable Federal statutes or regulations. A person must be designated in each State in which the applicant expects to operate,
even if it merely passes through the State. If the applicant chooses to use a Process Agent Service, a letter must be submitted
with the completed Form MCSA-1 informing the FMCSA of this decision. Applicants must ensure that the Process Agent Service
electronically files the BOC-3 with FMCSA within 90 days of the date the Form MCSA-1 is filed. An applicant may not operate until
the BOC-3 has been filed with, and approved by, FMCSA and an active USDOT Number has been issued. (A USDOT Number becomes active
only after process agent and applicable financial responsibility filings have been completed and approved by FMCSA, and/or any protests by persons opposing an application for
operating authority registration have been adjudicated.)
• Certifications and Oaths. Applicants must sign electronically the completed certification statements and oaths, as follows:
Entity
Party who must sign
Sole proprietorship
Owner
Partnership
One partner
Corporation
An officer (President, Vice President, etc.)
2. New Entrant Reapplication
There is a $300 fee for this transaction.
A new entrant whose USDOT Registration has been revoked, and whose operations have been placed out-of-service (OOS) by the
FMCSA, may file to re-apply for new entrant USDOT Registration no sooner than 30 days after the date of revocation. There are three
ways a motor carrier may re-apply if its U.S. DOT new entrant registration is revoked.
First, if the motor carrier failed a safety audit, the new entrant must: (1) submit an updated MCSA-1 Form, (2) submit evidence that
it has corrected the deficiencies that resulted in revocation of its registration and otherwise ensure that it will have basic safety
management controls in effect, and (3) begin the 18-month new entrant monitoring cycle again as of the date the re-filed application
is approved.
• Second, if the motor carrier’s new entrant registration was revoked because it failed to submit to a safety audit, it must: (1)
submit an updated MCSA-1 Form; (2) begin the 18-month new entrant monitoring cycle again as of the date of the re-filed
application is approved; and (3) submit to a safety audit.
• Third, if the new entrant is a for-hire motor carrier subject to the registration provisions under 49 U.S.C. 13901 and also has
had its operating authority registration revoked, it must re-apply for operating authority registration as set forth in part 365. If
revocation was based on the new entrant’s failure to file the minimum amounts of financial responsibility or designate agents for
service of process, it must also complete administrative filings as well in the reapplication process.
INSTRUCTIONS MCSA-1 [URS-1] Page 3 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
3. Reinstatement
There is a $10 fee for this transaction.
Check the “Reinstatement” box to re-apply to reinstate the registration of a motor carrier, freight forwarder, broker, cargo tank facility
or intermodal equipment provider that has been inactivated. Please be certain that all the requirements for operation have been
met, including those pertaining to filing a process agent designation form and filing evidence of the required minimum financial
responsibility requirements, if applicable.
4. Biennial Update
There is no fee for this transaction.
Check the “Biennial Update” box if the applicant has been issued a USDOT Number and is filing a biennial update in accordance with
49 CFR 390.201. The Form MCSA-1 is used for biennial updates every 24 months. A motor carrier may also update its record with
FMCSA at any given time within this 24-month period. A regulated entity that registers its vehicles in a State that participates in the
Performance and Registration Information Systems Management (PRISM) would fulfill the biennial update requirement through its
annual State Driver’s License Agency (SDLA) re-registration process. Once the applicant enters its USDOT Number in Section A, the
on-line Form MCSA-1 will automatically fill in the remainder of the fields on the MCSA-1 Form with the registration data most recently
provided by the applicant. The applicant must either certify that the existing registration information is correct, or re-enter any
registration information that is incorrect or that has changed from the data visible to the applicant on the Form MCSA-1.
Mexico-domiciled motor carriers holding a “Certificate of Registration” from the
former Interstate Commerce Commission, the Federal Highway Administration,
the former Office of Motor Carrier Safety or the Federal Motor Carrier Safety
Administration, that was issued before April 18, 2002, and which designate a
territorial scope of operations between points in specified States or between points in
the United States, must also file biennial updates in accordance with 49 CFR 390.19.
5. Name/Address/Form of Business Change
There is no fee for this transaction.
Check the “Name/Address/Form of Business Change” box to file changes to the legal name, doing business as (DBA) name, form of
business, or address. You will be required to file an updated Form MCSA-1 within 30 days of a change in your name, address, or form
of business.
6. Notification of Transfers of Operating Authority Registration
There is no fee for this transaction.
Check the “Notification of Transfers of Operating Authority Registration” box to notify FMCSA of a transfer of operating authority
registration. Both the transferor and transferee are required to fill out Section O of the Form MCSA-1 within 30 days of a transfer of
operating authority registration. If the transferee does not currently have a USDOT Number, it must complete the entire MCSA-1
Form. Both the transferor and the transferee are also required to provide a copy of the operating authority registration that is being
transferred by scanning and uploading a copy of the document along with the transfer notification.
7. Other
Check the “Other” box to update registration information, such as vehicle information, driver information, etc. Also check this box to
indicate updates to registration information made more frequently than the biennial update schedule.
An applicant applying for temporary authority can select the “other” registration box as a reason to file. Applications for temporary
authority are described in 49 CFR 365.107(e). Applications for temporary authority will be entertained only in exceptional
circumstances (i.e., natural disasters or national emergencies) when evidence of immediate service need can be specifically
documented in a narrative supplement appended to Form MCSA-1 for motor property carriers and motor passenger carriers. Only a
U.S.-domiciled motor carrier is eligible for temporary operating authority registration. Applicants must submit an MCSA-1 Form and
a letter indicating need for emergency temporary authority. The 10-day protest period for temporary authority will be waived and
the authority will be suspended after 120 days. The filing fee for an application for motor carrier temporary authority issued in an
emergency situation is $100.
INSTRUCTIONS MCSA-1 [URS-1] Page 4 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
LINE-BY-LINE INSTRUCTIONS
• These instructions will assist applicants in completing the Form MCSA-1 accurately. A Form MCSA-1 that does not include all
of the required information or contains incorrect information will be rejected by FMCSA and may result in loss of fees.
• The application must be completed in English.
• Applicants should print and retain a copy of the completed Form MCSA-1 and the instructions for their records.
Section
A
BUSINESS DESCRIPTION
(To be completed by all, except for those only providing
notification of transfers of operating authority registration)
Beginning on Page 3
1. LEGAL BUSINESS NAME. Provide applicant’s full legal business name—the name of the sole proprietor or partnership, the name
of the limited liability company as it appears on the articles of organization, or the complete corporate name as it appears on the
incorporation certificate. It is important to spell, punctuate and space accurately the words forming the name of the registered
entity. For example, FMCSA regards each of the following as a separate entity: John Jones; Harry L. Jones & John Jones; John Jones
Trucking, Inc.
2. DOING BUSINESS AS NAME (if different from Legal Business Name). If the applicant uses a trade name that differs from its
legal business name as shown in block 1, that name should be entered. Only one trade name, however, is permitted. For example: If
the applicant is “John Jones,” doing business as “Quick Way Trucking,” “John Jones” should be entered as the Legal Business Name,
and “Quick Way Trucking” should be entered as the Doing Business As Name. If the applicant does not have a trade name, leave this
item blank.
3. PRINCIPAL ADDRESS (Principal Place of Business). Enter the principal address where the company is physically located
and engaged in business operations related to the transportation of persons or property, and where safety records are regularly
maintained. This address will be used by FMCSA for on-site visits to entities it regulates for the purpose of conducting safety audits,
investigations, and other activities. A P.O. Box will not be accepted by FMCSA as a principal address. The principal place of business
address is where all records must be kept and be made available for inspection upon request by an authorized representative of the
FMCSA. A terminal address may be used here as long as it meets the principal place of business definition. Use the two-letter postal
abbreviation for the State or the abbreviation of the Canadian Province/Territory. If the applicant is domiciled in Mexico, enter the
“Colonia” or “Barrio” where the principal place of business is located.
4. MAILING ADDRESS. If the applicant receives mail at an address other than the principal place of business address given, please
provide it here. This address may be either a street name and number or a P.O. Box. If the applicant’s mailing address is its principal
place of business address, check the box marked “SAME AS PRINCIPAL ADDRESS” and leave the mailing address blank.
NOTE: Applicants must give FMCSA written notice within 30 days of any change in their business or mailing address. Follow the directions for “Name/
Address/Form of Business Change” and file the completed Form MCSA-1 with FMCSA. This will ensure that applicants receive notices from FMCSA and
that documents filed on their behalf are included as part of the applicant’s file. If a sole proprietor provides personal information on the Form MCSA-1,
this information will be publicly available on FMCSA websites. This published information may include, but IS NOT LIMITED TO, the sole proprietor owner/
operator’s home address, telephone number and e-mail address when the contact information serves as the business contact information.
Mexico-Domiciled Motor Carriers: If an applicant is a Mexico-domiciled motor carrier and also maintains an office in the United States, this information
should also be provided in response to Question 38 of Form MCSA-1.
5. COUNTRY OF DOMICILE OF PRINCIPAL PLACE OF BUSINESS. The applicant should indicate the country in which its principal
place of business is located. Check the appropriate box and include the RFC (Registro Federal de Contribuyentes or Federal
Taxpayer Registration) number for a company in Mexico or NSC (National Safety Code) number(s) for a company in Canada, as
applicable. If applicants have more than one NSC number, you will need to scan and upload the additional information when you
file your application.
6. PRINCIPAL BUSINESS TELEPHONE NUMBER. Enter the telephone number, including area code, of the principal place of business.
Please include the country code if the applicant is not domiciled in the United States.
7. PRINCIPAL BUSINESS FAX NUMBER (optional). Enter the fax number, including area code, of the principal place of business.
Please include the applicant’s country code if the applicant is not domiciled in the United States.
8. PRINCIPAL BUSINESS CELL PHONE NUMBER (optional). Enter the cell phone number, including area code, of the principal place
of business. Please include the applicant’s country code if the applicant is not domiciled in the United States.
9. USDOT NUMBER. Entities that already have been issued a USDOT Number must provide it. Applicants that have not obtained a
USDOT Number will be issued one after completion of the registration process. Applicants must obtain an active USDOT Number
before beginning operations.
INSTRUCTIONS MCSA-1 [URS-1] Page 5 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
10. IRS TAX ID NUMBER.* Enter the employer identification number (EIN) assigned to the company by the Internal Revenue Service.
*Sole proprietor owner/operators who do not have an EIN may submit their Social Security Number (SSN) instead of the EIN but are encouraged to obtain
an EIN rather than using an SSN to register for a USDOT Number.
11. DUN AND BRADSTREET NUMBER. Enter the business number issued to the applicant by Dun & Bradstreet, if known.
12. FORM OF BUSINESS. Check all boxes that apply to applicant’s form of business:
• Sole Proprietor—An individual who owns and operates a business normally in his or her legal name and in which there is no
legal distinction between the owner and the business. In some jurisdictions the proprietor can use a trade name or business
name other than his or her legal name, but the individual is also required to file a ‘doing business as (dba)’ statement with local
authorities. Every asset of the business is owned by the proprietor and all debts of the business are his or hers as well.
• Partnership—Two or more individuals operating as co-owners.
• Corporation—A legal entity created under the laws of a State, owned by shareholders whose liability for corporate debts is
limited. Enter State of incorporation.
• Limited Liability Company—An entity created under the laws of a State that provides limited liability to its owners, with
characteristics of both a corporation and a partnership or sole proprietorship (depending on how many owners there are).
• Unit of State or Local Government—An agency, department, commission, bureau, office, or other entity that is in any branch
of a State or Local government.
• Limited Liability Partnership (LLP)—A partnership in which some or all partners (depending on the jurisdiction) have limited
liability. In an LLP, no partner is responsible or liable (directly or indirectly) for an obligation of the partnership due to another
partner’s misconduct or negligence, thus shielding innocent members of these partnerships from liability.
• Trust—A relationship whereby property (real or personal, tangible or intangible) is transferred by one party (settlor) to be held
by another party (trustee) for the benefit of a third party or parties (beneficiary(ies)). In effect, a trust is a legal device designed
to provide financial assistance or something of value to someone without giving the person total control over the trust assets.
It may be revocable or irrevocable, express or implied. The trustee owes a fiduciary duty to the beneficiaries (the beneficial
owners of the trust property) and is obligated to administer the trust in accordance with both the terms of the trust and the
governing law.”
• Other—If the business forms listed above do not apply, please check the “Other” category and describe the form of business it
intends to conduct.
13. OWNERSHIP and CONTROL. Applicants must check the appropriate box regarding citizenship of the principal owner or owners.
The term “citizen” includes a sole proprietor, partner, corporation, or limited liability company.
14. NAME(S) AND TITLE(S) OF SOLE PROPRIETOR, PARTNERS OR OFFICER(S). List the names of the owners and, as appropriate,
officers of the entity. If the applicant is a sole proprietor, please provide the applicant’s full name. If the applicant is organized as a
partnership, please provide the full names of the general and limited partners. If the applicant is organized as a corporation, please
provide the full names of the officers and their respective titles. If the applicant is organized as a limited liability company, please
provide the full names of the officers and their respective titles.
15. OPERATION CLASSIFICATION. Check all classifications that apply. If “Other,” enter the type of operation in the space provided.
• For-Hire Motor Carrier—Transportation by a motor carrier for compensation, including:
oo
Property: Transportation of general freight, hazardous materials or household goods. This category includes transportation
exempt from the commercial registration requirements in Title 49 U.S.C. chapter 139. These exemptions can be found in 49
U.S.C. chapter 135.
oo
Passengers:
Charter & special operations—Charter service is the transportation of groups, assembled by someone other than the carrier,
who collectively contract with the motor carrier for the exclusive use of vehicle(s) for the duration of a particular trip or tour.
The passengers must travel together for the entire trip. Special operations include almost any type of service that is neither
charter transportation nor regularly-scheduled service over fixed routes. The carrier assembles the group through the sale of
individual tickets and generally offers some service feature in addition to transportation between two points.
Regular route—Regularly scheduled service between specific points operated in accordance with a published schedule. It is
not necessary for privately owned applicants to specify a particular route. However, public entities must describe the specific
routes over which they propose to operate in Section G of this Form and must file new applications whenever seeking to add
new routes after initial registration.
Limousine/van operations—Operation of a passenger vehicle usually built on a lengthened automobile chassis designed or
used to transport 15 or fewer passengers, including the driver.
FTA grantee—A motor carrier of passengers providing transportation service within a transit service area under an
agreement with a Federal, State, or local government funded, in whole or part, with a grant under 49 U.S.C. 5307, 5310, 5311,
5316 or 5317. Such carriers participate in the for-hire transportation of passengers between points in a transit service area
located in more than one State.
INSTRUCTIONS MCSA-1 [URS-1] Page 6 of 16
OMB No.: 2126-0051
oo
Expiration: 11/30/2016
Mexico-Owned, U.S.-Based Enterprise: A U.S.-based company owned or controlled by persons of Mexico. Transportation of
property by such an enterprise is limited to international cargo.
• Private Motor Carrier—Transportation by commercial motor vehicle, not for compensation, as defined in 49 CFR part 390.
oo
Property (Hazardous Materials): transports any amount of hazardous materials.
oo
Property (Non-Hazardous Materials): does not transport any hazardous materials.
oo
Passengers (Business): A private motor carrier engaged in the interstate transportation of passengers which is provided
in the furtherance of a commercial enterprise and not available to the public at large. Examples include companies that
use buses to transport their employees without collecting a fee from them, or professional entertainers who use buses to
transport themselves to or from performances. Commercial businesses that provide passenger transportation to the general
public and charge a fee are not private motor carriers of passengers (business).
oo
Passengers (Non-Business): A private motor carrier of passengers (nonbusiness) means a private motor carrier involved in
the interstate transportation of passengers not provided in the furtherance of a commercial enterprise and not available to
the public at large. Examples include churches, private schools, civic organizations, scout groups, and other organizations
that own or lease a vehicle for the private transportation of their membership. If any of these organizations makes passenger
transportation available to non-members and charges a fee for such service, it is operating as a for-hire carrier and is not a
private motor carrier of passengers (non-business).
oo
Migrant Workers: Interstate transportation of three or more migrant workers to or from their employment by any
commercial motor vehicle other than a passenger automobile or station wagon.
• Property Broker—An entity that arranges for the interstate transportation of cargo belonging to others, using for-hire motor
carriers subject to the commercial registration requirements to provide the actual transportation.
• Freight Forwarder—An entity that holds itself out to provide transportation of cargo belonging to others, using for-hire motor
carriers subject to the commercial registration requirements to provide the actual interstate transportation. In the ordinary
course of business, freight forwarders: (1) assemble and consolidate shipments, (2) conduct break bulk and distribution
operations, and (3) assume responsibility for transportation of property from place of receipt to the place of destination.
Freight Forwarders may or may not operate trucks.
• Government Entity—A U.S. Federal Government agency, State Government agency, local Government agency or Indian Tribe.
• Cargo Tank Facility—An entity that: (1) manufactures, repairs, inspects, tests, qualifies, or maintains a cargo tank to ensure that
the cargo tank conforms to 49 CFR part 178, subpart J, and 49 CFR part 180, subpart E; (2) alters the certificate of construction
of cargo tank; (3) ensures the continuing qualification of a cargo tank by performing a function prescribed in 49 CFR part 178 or
180; or (4) makes any representation indicating compliance with one or more of the requirements of 49 CFR part 178 or 180.
• Intermodal Equipment Provider (IEP)—Any person who interchanges intermodal equipment with a motor carrier pursuant to
a written interchange agreement or has a contractual responsibility for the maintenance of the intermodal equipment.
• Driveaway/Towaway Operation—An operation in which an empty or unladen motor vehicle with one or more sets of wheels
on the surface of the roadway is being transported: (1) between a vehicle manufacturer’s facilities; (2) between a vehicle
manufacturer and a dealership or purchaser; (3) between a dealership, or other entity selling or leasing the vehicle, and a
purchaser or lessee; (4) to a motor carrier’s terminal or repair facility for the repair of disabling damage (as defined in section
390.5) following a crash; or (5) to a motor carrier’s terminal or repair facility for repairs associated with the failure of a vehicle
component or system; or (6) by means of a saddle-mount or tow-bar.
• Other—An entity that transports property or passengers by a classification of operation not described above. Please enter
other classification description.
16. COMPANY CONTACT PERSON. The person at the applicant’s place of business who prepares the Form MCSA-1 or otherwise
assists in completing the application. Provide the contact person’s name, title, address, telephone number, fax number (optional), cell
phone number (optional) and e-mail address (optional). This individual may be contacted by FMCSA if there are questions concerning
this application.
17. APPLICANT’S REPRESENTATIVE. If someone other than the applicant prepares the Form MCSA-1, or otherwise assists the
applicant in completing the application, provide the representative’s name, title, or relationship to the applicant, address, telephone
number, and fax number (optional), cell phone number (optional) and e-mail address (optional). This individual may be contacted by
FMCSA if there are questions concerning this application.
18. CERTIFICATION STATEMENT. This certification applies to the representations made by the applicant on the Form MCSA-1.
Applicants are certifying to the truthfulness of statements in this form under penalty of perjury.
INSTRUCTIONS MCSA-1 [URS-1] Page 7 of 16
OMB No.: 2126-0051
Section
B
Expiration: 11/30/2016
OPERATION CLASSIFICATION AND INFORMATION
(To be completed by all motor carriers, freight forwarders with
vehicles, and intermodal equipment providers)
Beginning on Page 5
19. TYPE OF OPERATION. Check the appropriate type(s) of operation:
Interstate (Non-HM)—Transportation of passengers or property: (1) across State lines, including international boundaries; or (2)
within one State as part of a through movement that originates or terminates in another State or country.
Interstate (HM)—Transportation of any amount of hazardous material: (1) across State lines, including international boundaries;
or (2) entirely within one State as part of a through movement that originates or terminates in another State or country.
Intrastate (Non-HM)—Transportation of passengers or property entirely within one State that is not part of a through movement
that originates or terminates in another State or country.
Intrastate (HM)—Transportation of any amount of hazardous material entirely within the boundaries of a single State that is not
part of a through movement that originates or terminates in another State or country.
NOTE: Any driver who engages in both interstate and intrastate
transportation should be counted as an interstate driver.
20. CARGO. If the applicant will transport or handle property, check each type of cargo that the applicant will transport or handle. If
“Other” is checked, enter the name of the commodity in the space provided.
21. CARRIER MILEAGE. Enter the total mileage of all CMVs to the nearest 10,000 miles operated by the applicant for the previous 12
months (whether leased or owned). If the applicant has been in operation for less than 12 months, enter mileage operated to date. If
the applicant has not operated within the last 12 months, enter the number “0.”
22. (a) NUMBER OF VEHICLES WITH A GROSS VEHICLE WEIGHT RATING (GVWR), GROSS COMBINATION WEIGHT RATING
(GCWR), GROSS VEHICLE WEIGHT (GVW) OR GROSS COMBINATION WEIGHT (GCW) OF 10,001 POUNDS OR MORE THAT ARE
OPERATED (if update) OR WILL BE OPERATED (if new application) IN THE U.S. Enter the total number of commercial motor
vehicles owned, term-leased or trip-leased by the applicant on the date the Form MCSA-1 is submitted and that have a GVWR, GCWR,
GVW or GCW of 10,001 pounds or more.
A CMV is operated for purposes of this question if the vehicle is registered under Federal or State law, or both, in the name of the
carrier, or is controlled by the carrier under a trip lease or term lease agreement (more than 30 days) during any given year. If a
freight forwarder operates CMVs, it is also required to enter its fleet size on the MCSA-1 Form. Both a motor carrier and a freight
forwarder (if operating CMVs) must include the number of CMVs operated under a trip lease or long term lease agreement in their
fleet size determinations.
If an intermodal equipment provider, enter the trailer/chassis-equipment “serviced” and used to interchange with a commercial
motor vehicle.
Driveaway/Towaway Operations—Persons who conduct driveaway operations do not need to provide vehicle information to
FMCSA due to the nature of this service. However, those persons who provide towaway service must provide vehicle information
to the Agency.
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.
• Mini-bus—A motor vehicle designed or used to transport 16 or more passengers, including the driver, and typically built on
a small truck chassis. A mini-bus has a smaller seating capacity than a motor coach.
• Van—A small motor vehicle designed or used to transport 15 or fewer passengers, including the driver.
• Limousine—A passenger vehicle usually built on a lengthened automobile chassis designed or used to transport 15 or fewer
passengers, including the driver.
22. (b) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW OR GCW OF 10,001 POUNDS OR MORE THAT ARE OPERATED
OR WILL BE OPERATING IN CANADA OR MEXICO (To be completed by U.S.-domiciled motor carriers only). Enter the number of
commercial motor vehicles that are operated or will be operating in Canada or Mexico that have a GVWR, GCWR, GVW or GCW of
10,001 or more pounds.
22. (c) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW OR GCW OF 10,001 POUNDS OR MORE THAT ARE OPERATED OR
WILL BE OPERATING IN INTERSTATE COMMERCE. Enter the number of commercial motor vehicles that are operated or will be
operating in interstate commerce that have a GVWR, GCWR, GVW or GCW of 10,001 or more pounds.
INSTRUCTIONS MCSA-1 [URS-1] Page 8 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
22. (d) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW OR GCW OF 10,001 POUNDS OR MORE THAT ARE OPERATED OR
WILL BE OPERATING SOLELY IN INTRASTATE COMMERCE. Enter the number of commercial motor vehicles that are operated or will
be operating solely in intrastate commerce that have a GVWR, GCWR, GVW or GCW of 10,001 or more pounds.
23. (a) NUMBER OF DRIVERS WHO OPERATE OR WILL BE OPERATING IN THE U.S. Enter the number of interstate and intrastate
drivers used by the applicant on an average workday in the United States. Part-time, casual, term-leased, trip-leased and company
drivers should be included. Enter the total number of drivers who have a commercial driver’s license (CDL). Enter the number of
drivers operating within a 100 air-mile radius of the driver’s normal work reporting location in each category and the number of
drivers operating beyond a 100 air-mile radius of the driver’s normal work reporting location in each category.
Interstate—The driver transports passengers or property: (1) across State lines, including international boundaries; or (2) entirely
within one State as part of a through movement that originates or terminates in another State or country.
Solely Intrastate—The driver transports passengers or property entirely within one State that is not part of a through movement
that originates or terminates in another State or country.
NOTE: Any driver who engages in both interstate and intrastate
transportation should be counted as an interstate driver.
23. (b) NUMBER OF DRIVERS WHO OPERATE OR WILL BE OPERATING IN CANADA OR MEXICO. (To be completed by U.S.domiciled motor carriers only). Enter the number of interstate drivers used or expected to be used by the applicant on an average
workday in Canada or Mexico.
Section
C
HAZARDOUS MATERIALS (HM)
(To be completed only by HM motor carriers/shippers)
Beginning on Page 7
For the purposes of this section, the terms “bulk” and “non-bulk” are defined in 49 CFR 171.8, as follows:
Bulk: A packaging, without any intermediate form of containment, having a maximum capacity greater than 119 gallons for
liquids, 882 pounds or 119 gallons for solids, or 1,000 pounds water capacity for gases.
Non-Bulk: A packaging having a capacity equal to or less than 119 gallons for liquids, 882 pounds or 119 gallons for solids, or
1,000 pounds water capacity for gases.
NOTE: The terms “bulk” and “non-bulk” used in this section refer
specifically to the HM Regulations; therefore, it is important for the
applicant to know the distinction between these terms and their use.
24. HAZARDOUS MATERIALS CARRIED OR SHIPPED. If the applicant is: (1) a motor carrier of hazardous materials, or (2) a motor
carrier and shipper of hazardous materials, complete the appropriate section for each type of hazardous materials (HM) the applicant
transports and/or ships. In the columns to the right of each category, check “C” for motor carrier and/or “S” for a shipper. Check “B” if
the HM is transported in bulk and/or “NB” if the HM is transported in non-bulk quantities.
Section
D
HAZARDOUS MATERIALS PERMITTING
(To be completed only by HM motor carriers applying for a hazardous
materials safety permit under 49 CFR part 385, subpart E)
Beginning on Page 8
For the purposes of this section, the terms “bulk” and “non-bulk" are defined as follows:
For materials Poison by Inhalation in Zone B, bulk has the same meaning as in Section C.
For materials Poison by Inhalation in Zones C and D, the capacity of the packaging is 3,500 gallons or more.
For Compressed or Refrigerated Liquefied Methane, Liquefied Natural Gas, or Liquefied Gas with a Methane Content of at least 85
Percent, the capacity of the packaging is 3,500 gallons or more.
Non-bulk has the same meaning as in Section C.
25. Check all boxes that apply indicating the type of hazardous materials your company transports. If you do not transport hazardous
materials in the types and quantities listed on the application in Section C, you do not need to complete this section, nor do you need
a Hazardous Materials Safety Permit.
INSTRUCTIONS MCSA-1 [URS-1] Page 9 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
26-30. If you checked a box in question 25, answer questions 26 through 30.
31. CERTIFICATION STATEMENT. To be completed by an authorized official. The authorized person must electronically sign, date
and provide his/her title.
Section
E
CARGO TANK FACILITY
(To be completed by applicants registering as cargo
tank facilities under 49 CFR part 107, subpart F)
Beginning on Page 9
• A Cargo Tank (CT) Number is required for a company that engages in the manufacture, assembly, inspection, testing,
certification (Design Certifying Engineer) or repair of a cargo tank or of a cargo tank motor vehicle.
• FMCSA will assign a single USDOT Number to the registering company and a unique CT Number for each cargo tank facility
registered. All assigned CT Numbers will be associated with the USDOT Number assigned to your company.
32. For each cargo tank facility being registered, please provide the following information:
Functions. Check the box corresponding to the description of the specific function to be performed on cargo tanks or cargo tank
motor vehicles.
Exemptions/Special Permits. For each function checked, list all corresponding exemptions or special permits issued by the
Department of Transportation pursuant to 49 U.S.C. 5117.
Vehicles. For each function checked, check all boxes corresponding to the types of DOT specification and special permit cargo
tanks or cargo tank motor vehicles which the registrant intends to manufacture, assemble, repair, inspect, test or certify. For
example, if you will perform “External Visual Inspections,” check all vehicle types indicated in the corresponding row on which that
function will be performed. This information is not required for the “Component Manufacture” function.
Mobile Testing Information. Check the appropriate box indicating whether the facility uses mobile testing/inspection equipment
to perform inspections, tests, or repairs at a location other than the address listed in section A of this application.
Process Agent. If the registrant is not a resident of the United States, list the name and address of a permanent resident of the
United States designated in accordance with 49 CFR 105.40 to serve as an agent for service of process. A post office box is not a
valid address for a process agent.
Responsible Person (Facility Location). Provide the title, first and last name, phone number, fax number and e-mail address
for the person at the facility location responsible for compliance with the applicable requirements of chapter 1, title 49 Code of
Federal Regulations.
Design Certified Engineers/Registered Inspectors. Provide the name, address, city, state, zip/postal code, and type for each
registered inspector or design certified engineer employed by the company to conduct certification, inspection, or testing functions.
Non-Employee Design Certified Engineers/Registered Inspectors. If the registrant engages non-employees to perform
certification, inspection or testing functions, provide the name, address, city, state, zip/postal code, and certification number of
each person performing such functions.
Stamp: F or each person who manufactures a cargo tank or cargo tank motor vehicle, provide the stamp type, certification number,
authorization date and expiration date of the manufacturer’s current American Society of Mechanical Engineers (ASME)
Certificate of Authorization for the use of the ASME “U” Stamp.
For each person who repairs a cargo tank or cargo tank motor vehicle, provide the stamp type, certification number,
authorization date and expiration date of the repair facility’s current National Board Certificate of Authorization for the
use of the “R” stamp or ASME Certificate of Authorization for the use of the ASME “U” Stamp.
Certification Statement. The cargo tank certification statement must be completed by the person responsible for compliance
with the applicable requirements of chapter 1, title 49, Code of Federal Regulations. Provide the name, title and e-mail address of
the certifying official.
INSTRUCTIONS MCSA-1 [URS-1] Page 10 of 16
OMB No.: 2126-0051
Section
F
Expiration: 11/30/2016
TRANSPORTATION OF HOUSEHOLD GOODS
(To be completed by household goods motor carriers, household
goods brokers, and household goods freight forwarders)
Beginning on Page 11
33. CERTIFICATION: ARBITRATION PROGRAM AND TARIFF.
(1) I f the applicant is a for-hire household goods motor carrier (as defined in 49 U.S.C. 13102(12)), the applicant must certify that
it participates in a program offering arbitration as a means of settling loss and damage claims and disputes regarding carrier
charges in addition to those collected at delivery. This is a condition of registration. Also, if the applicant is registering as a
motor carrier, broker or freight forwarder of household goods, applicant must certify it is fit, willing and able to provide the
service and comply with all applicable statutory and regulatory requirements.
(2) A
pplicants applying for registration as a household goods motor carrier must provide certain information regarding their
arbitration program and tariff. They must also certify they are familiar with FMCSA’s consumer protection requirements
applicable to household goods transportation.
The signature at the bottom of this item should be that of the company official who completes the Applicant’s Oath.
Section
G
TRANSPORTATION OF PASSENGERS
(To be completed by passenger carriers)
Beginning on Page 12
34. GOVERNMENT FUNDING STATUS. Specify the nature of governmental financial assistance you receive, if any, by checking the
appropriate button (check only one).
Applicants that do not receive any government funding or use equipment acquired with governmental financial assistance should select
the “Non-recipient” response.
35. PASSENGER CARRIER COMPLIANCE CERTIFICATION. Applicants transporting passengers must certify that they are fit, willing
and able to comply with all applicable statutory and regulatory requirements.
Section
H
SCOPE OF AUTHORITY
(To be completed by passenger carriers)
Beginning on Page 13
36. All Passenger Carrier applicants must complete this section. Check all boxes that apply.
The types of operating authority designated in this section correspond with the operation classifications in Section A of this form.
NOTE:
• “Regular Routes” refer only to passenger carriers that provide scheduled service over
regular routes and, in the case of public recipients of governmental assistance, operate
over named roads or highways between designated points.
• Passenger carriers engaged in charter and special operations do not provide scheduled
service over regular routes.
• Public recipients of governmental assistance that request operating authority over
regular routes must submit a detailed narrative description of the route(s) and a
corresponding map that graphically displays the route(s), which must be scanned and
uploaded along with the application.
INSTRUCTIONS MCSA-1 [URS-1] Page 11 of 16
OMB No.: 2126-0051
Section
I
Expiration: 11/30/2016
COMMERCIAL ZONE OPERATIONS
(To be completed by Mexico-domiciled motor carriers operating
exclusively within U.S.-Mexico international border commercial zones)
Beginning on Page 13
37. SCOPE OF REGISTRATION. If applicant is domiciled in Mexico, please check the appropriate box.
38. UNITED STATES ADDRESS. If applicant maintains an office within the continental United States, please provide the complete
address, telephone number and fax number.
Section
J
NON-NORTH AMERICA-DOMICILED CARRIERS
(To be completed by motor carriers not domiciled in
the United States, Mexico, or Canada)
Beginning on Page 14
39. SCOPE OF REGISTRATION. If applicant is domiciled in a non-North American country, please check the appropriate box.
40. PRINCIPAL BORDER CROSSING POINTS. Applicant must indicate the principal U.S.–Mexico international border crossing points,
including the city and State, that it intends to use.
41. UNITED STATES ADDRESS. If applicant maintains an office within the continental United States, please provide, the complete
address, telephone number and fax number.
Section
K
ADDITIONAL INFORMATION
(To be completed by for-hire motor carriers and private hazardous materials carriers, including
those domiciled in Mexico and outside of North America, and by brokers and freight forwarders)
Beginning on Page 15
42. FINANCIAL RESPONSIBILITY. For-hire motor carriers of property and passengers (both exempt and non-exempt), freight
forwarders and private carriers of hazardous materials must comply with requirements for demonstrating minimum financial
responsibility for bodily injury and property damage (49 CFR part 387) and submit evidence of financial responsibility to FMCSA.
Property brokers and freight forwarders must submit evidence of a surety bond or trust fund to ensure that the transportation for
which they arrange is provided. Motor carriers and freight forwarders of household goods must also file evidence of cargo insurance.
Check each box that describes the type of business the applicant will be conducting. Applicant must contact its insurance company
or surety company and ensure that it electronically submits the required information in a timely manner.
Motor carriers of property and passengers and freight forwarders, in lieu of filing evidence of commercial insurance may also apply
for self-insurance authorization on FMCSA prescribed form BMC-40, or have active authority to self-insure bodily injury and property
damage and/or cargo liability in accordance with 49 U.S.C. 13906, 31138 and 31139.
If applicant is domiciled in Mexico and has been issued a Certificate of Registration, to operate exclusively within a border commercial
zone, it is not required to file evidence of financial responsibility with FMCSA. However, the following documents must be carried on
each of applicant’s motor vehicles when they cross the border:
• A current Form MCS-90 indicating insurance coverage for 24 hours or longer.
• The Certificate of Registration.
• An insurance identification card, binder, or other document issued by an authorized insurer which specifies both the effective
date and the expiration date of the insurance coverage.
INSTRUCTIONS MCSA-1 [URS-1] Page 12 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
FINANCIAL RESPONSIBILITY: MINIMUM COVERAGE
PASSENGER CARRIERS
Seating Capacity
Amount
Any vehicle with a seating capacity of 16 or more passengers, including the driver*
$5,000,000
Any vehicle with a seating capacity of 15 or fewer passengers, including the driver*
$1,500,000
*Unless exempt under section 387.27(b).
NOTE for Certain FTA Grantees: The above requirements do not apply to entities providing transportation service within a transit service area under
an agreement with a Federal, State, or local government funded, in whole or in part, with a grant under 49 U.S.C. 5307, 5310, or 5311, including
transportation designed and carried out to meet the special needs of elderly individuals and individuals with disabilities. In any case in which the
transit service area is located in more than one State, the minimum level of financial responsibility for such motor vehicle will be at least the highest
level required for any of such States. If an FTA Grantee provides service to a transit service area within a single State but participates in providing
interstate transportation by entering into a through ticketing arrangement with an interstate carrier, it is subject to the minimum level of financial
responsibility for the State in which it operates.
MOTOR PROPERTY CARRIERS and FREIGHT FORWARDERS OPERATING MOTOR VEHICLES
Bodily Injury and Property Damage Liability Requirements
Amount of Coverage Required
Kind of Equipment
Commodity
Freight vehicles under 10,001
pounds (4536 kilograms) GVWR
Property (non-hazardous).
$300,000
Freight vehicles of 10,001 pounds
(4536 kilograms) or more GVWR
Property (non-hazardous).
$750,000
Freight vehicles of 10,001 pounds
(4536 kilograms) or more GVWR
Hazardous substances, as defined in 49 CFR 171.8,
transported in cargo tanks, portable tanks, or hoppertype vehicles with capacities in excess of 3,500 water
gallons, or in bulk Class A or B explosives, poison gas
(Poison A), liquefied compressed gas or compressed
gas, or highway route controlled quantity or
radioactive materials as defined in 49 CFR 173.455.
$5,000,000
Freight vehicles of 10,001 pounds
(4536 kilograms) or more GVWR
Oil listed in 49 CFR 172.101; hazardous waste,
hazardous materials and hazardous substances
defined in 49 CFR 171.8 and listed in section 172.101,
but not mentioned in the previous or next category.
$1,000,000
Freight vehicles under 10,001
pounds (4536 kilograms) GVWR
Any quantity of Divisions 1.1, 1.2, or 1.3 material; any
quantity of Division 2.3, Hazard Zone A, or Division
6.1, Packing Group I, Hazard Zone A material; or
highway route controlled quantities of a Class 7
material as defined in 49 CFR 173.403.
$5,000,000
Cargo Insurance Requirements
Motor carriers and freight
forwarders of household goods
$5,000 for loss of or damage to property carried on any one vehicle and $10,000
for the aggregate losses or damages occurring at any one time or place
PROPERTY CARRIERS
A property broker must have a surety bond or trust fund in effect for at least $10,000 (for general freight) or $25,000 (for
household goods).
SELF-INSURED
Approval by FMCSA to self-insure in accordance with 49 U.S.C. 13906, 31138 and 31139 and regulations implementing these
statutory provisions.
MOTOR CARRIERS DOMICILED IN MEXICO
These carriers must carry the same amount of insurance coverage as U.S.-based motor carriers; however, they do not need to
file evidence of insurance with FMCSA when operating exclusively within a border commercial zone. These carriers must carry
in each of their vehicles when crossing into the U.S. a Form MCS-90, a Certificate of Registration, and acceptable evidence of
required bodily injury and property damage insurance to cover the carrier’s operation during the time it is in the United States.
INSTRUCTIONS MCSA-1 [URS-1] Page 13 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
43. AFFILIATIONS WITH FMCSA LICENSED ENTITIES OR OTHER APPLICANTS APPLYING FOR USDOT NUMBER REGISTRATION.
Applicants must disclose certain information concerning affiliations with other entities registered with FMCSA (or its predecessor
agencies), or applying for registration with FMCSA, within the 3-year period preceding the filing of the application. For purposes of
completing the MCSA-1 form, the term “affiliation” means any past or current relationship, through common ownership, common
management, common control, or common familial relationship.
Applicants must indicate whether these entities have ever been disqualified from operating commercial motor vehicles in the United
States pursuant to Section 219 of the Motor Carrier Safety Improvement Act of 1999 (P. L. 106-159, December 9, 1999).
Section
L
SAFETY CERTIFICATIONS
(To be completed by Mexico-domiciled and non-North America-domiciled motor carriers)
Beginning on Page 17
44. SAFETY CERTIFICATIONS FOR MEXICO-DOMICILED AND NON-NORTH AMERICA-DOMICILED CARRIERS.
Mexico-domiciled and Non-North America-domiciled carriers must complete all applicable questions and attachments.
Section
M
COMPLIANCE CERTIFICATIONS
(To be completed by motor carriers, brokers, cargo tank facilities,
intermodal equipment providers, and freight forwarders)
Beginning on Page 19
45. Check the applicable box in response to items 1 through 8. Read the certification statement carefully.
Section
N
APPLICANT'S OATH
(To be completed by applicant's authorized official)
On Page 20
46. All applicants must complete this section. False certifications are subject to the penalties described in the oath. Type or print the
name and title of an individual authorized to sign documents on behalf of the applicant. The authorized signer is one of the following:
• In the case of a sole proprietorship, the owner.
• In the case of a partnership, an official partner.
• In the case of a corporation, an authorized corporate officer.
• An individual with power of attorney to act on behalf of the applicant (proof of the power of attorney must be uploaded and
submitted with the application).
INSTRUCTIONS MCSA-1 [URS-1] Page 14 of 16
OMB No.: 2126-0051
Section
O
Expiration: 11/30/2016
NOTIFICATION OF TRANSFERS OF OPERATING AUTHORITY REGISTRATION
(To be completed by both the transferee and the transferor)
Beginning on Page 21
47. LEGAL BUSINESS NAME. Provide transferee’s full legal business name—the name of the sole proprietor or partnership, the
name of the limited liability company as it appears on the articles of organization, or the complete corporate name as it appears on
the incorporation certificate. It is important to spell, punctuate and space accurately the words forming the name of the registered
entity. For example, FMCSA regards each of the following as a separate entity: John Jones; Harry L. Jones & John Jones; John Jones
Trucking, Inc.
48. DOING BUSINESS AS NAME (if different from Legal Business Name). If the transferee uses a trade name that differs from its
legal business name as shown in block 1, that name should be entered. Only one trade name, however, is permitted. For example:
If the applicant is “John Jones,” doing business as “Quick Way Trucking,” “John Jones” should be entered as the Legal Business Name,
and “Quick Way Trucking” should be entered as the Doing Business As Name. If the applicant does not have a trade name, leave this
item blank.
49. PRINCIPAL ADDRESS (PRINCIPAL PLACE OF BUSINESS). Enter the principal address where the transferee is physically located
and engaged in business operations related to the transportation of persons or property, and where safety records are regularly
maintained. This address will be used by FMCSA for on-site visits to entities it regulates for the purpose of conducting safety audits,
investigations, and other activities. A P.O. Box will not be accepted by FMCSA as a principal address. A terminal address may be used
here as long as it meets the principal address (principal place of business) definition. Use the two-letter postal abbreviation for the
State or the abbreviation of the Canadian Province/Territory. If the applicant is domiciled in Mexico, enter the “Colonia” or “Barrio”
where the principal place of business is located.
50. MAILING ADDRESS. If the transferee receives mail at an address other than the principal place of business address given, please
provide it. This address can either include a street name and number or may be a P.O. Box. If the transferee’s mailing address is the same
as the principal place of business address, check the box marked “SAME AS PRINCIPAL ADDRESS” and leave the mailing address blank.
51. PRINCIPAL BUSINESS TELEPHONE NUMBER. Enter the principal telephone number, including area code, of the principal place
of business. Please include the country code if the transferee is not domiciled in the United States.
54. USDOT NUMBER. Entities that already have been issued a USDOT Number must provide it. Transferees that have not obtained a
USDOT Number will be issued one after completing the entire Form MCSA-1 registration process. Transferees must obtain an ‘active”
USDOT Number before beginning operations.
55 THROUGH 62. The transferor should enter essentially the same information requested of the transferee in questions 47 through
53. Question 54 is somewhat different in that the transferor will have a USDOT Number.
Both the transferor and transferee must provide a copy of the operating authority registration being
transferred by scanning and uploading a copy of the document along with the transfer notification.
Section
P
FILING FEE INFORMATION
(FMCSA does not refund filing fees)
Beginning on Page 22
63. Enter the type of filing. If this is a New Registration, enter all the entity types for which the applicant is registering. If applicants
apply to register as more than one of the following classifications (motor carrier, freight forwarder, broker, intermodal equipment
provider or cargo tank facility) the applicant must tender $600 for each. If this is a request for reinstatement of registration, enter all
the entity types for which reinstatement is sought.
Indicate how the applicant intends to pay. Not all transactions require a fee.
INSTRUCTIONS MCSA-1 [URS-1] Page 15 of 16
OMB No.: 2126-0051
Expiration: 11/30/2016
Attachments to Section
L
Beginning on Page 23
If applicants are motor carriers domiciled in Mexico or outside of North America, they are required to complete
Attachments A-D and F. If such applicants transport hazardous materials, they should also complete Attachment E.
OTHER CONSIDERATIONS
Before beginning operation, an applicant may be responsible for complying with other
laws, such as State registration requirements and payment of fuel taxes.
INSTRUCTIONS MCSA-1 [URS-1] Page 16 of 16
OMB No.: 2126-0051
FOR FMCSA USE ONLY
Date Received:
Inactive:
USDOT Number:
Active:
Expiration: 11/30/2016
The collection of this information is authorized under the provisions of 49 CFR, Parts 390-399.
Public reporting for this collection of information is estimated to be 1 hour, 20 minutes per response, including the time for reviewing the instructions and
completing and reviewing the data inserted on the form electronically. All responses to this collection of information are mandatory, and will be provided
in confidence to the extent allowed by law. Notwithstanding any other provision of law, no person is 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 valid OMB Control Number for this information collection is 2126-XXXX. 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-MBI, U.S. Department of Transportation, Washington, D.C. 20590.
United States Department of Transportation
Federal Motor Carrier Safety Administration
FMCSA Registration/Update(s)
(Application for USDOT Number/Operating Authority Registration)
FORM MCSA-1
Please read the instructions for this form carefully
before proceeding!
Form MCSA-1, attachments, and statements must be
completed in English.
There are seven reasons to file this form:
If your reason for filing this form is:
1. New Registration
The Filing Fee is: $300
If your reason for filing this form is:
2. New Entrant Reapplication
The Filing Fee is: $300
If your reason for filing this form is:
3. Reinstatement
The Filing Fee is: $10
If your reason for filing this form is:
4. Biennial Update
There is
No fee
If your reason for filing this form is:
5. Name/Address/Form of Business Change(s)
There is
No fee
If your reason for filing this form is:
6. Notification of Transfer of Operating Authority
Registration (Transferee and Transferor)
There is
No fee
If your reason for filing this form is:
7. Other
For each reason checked, please complete all appropriate sections of Form MCSA-1 as indicated on the next page.
FORM MCSA-1 [URS-1] Page 1 of 26
*(see instructions)
OMB No.: 2126-0051
TYPE OF OPERATION:
Motor Carrier (Domiciled in the U.S. or Canada) of:
Motor Carrier (Domiciled in Mexico) of:
Motor Carrier (Not Domiciled in North America) of:
Broker of:
Household Goods
Expiration: 11/30/2016
If reasons 1 or
2 were checked,
complete these
sections:
If reason 3 was
checked, complete
these sections:
If reasons 4, 5,
or 7 were checked,
complete these
sections:
If reason 6 was
checked, complete
these sections:
A,B,F,K,M,N,O,P
A,B,F,K,M,N,P
A,B,F,K,N
O
Hazardous Materials
Carrier/Shipper
A,B,C,D,K,M,N,O,P
A,B,C,D,K,M,N,P
A,B,C,D,K,N
O
Property
A,B,K,M,N,O,P
A,B,K,M,N,P
A,B,K,N
O
Passengers
A,B,G,H,K,M,N,O,P
A,B,G,H,K,M,N,P
A,B,G,H,K,N
O
Household Goods
A,B,F,I,K,L,M,N,O,P
A,B,F,I,K,L,M,N,P
A,B,F,I,K,N
O
Hazardous Materials
Carrier/Shipper
A,B,C,D,I,K,L,M,N,O,P
A,B,C,D,I,K,L,M,N,P
A,B,C,D,I,K,N
O
A,B,I,K,L,M,N,P
Property
A,B,I,K,L,M,N,O,P
A,B,I,K,N
O
Passengers
A,B,G,H,I,K,L,M,N,O,P A,B,G,H,I,K,L,M,N,P
A,B,G,H,I,K,N
O
Household Goods
A,B,F,J,K,L,M,N,O,P
A,B,F,J,K,N
O
A,B,F,J,K,L,M,N,P
Hazardous Materials
Carrier/Shipper
A,B,C,D,J,K,L,M,N,O,P
A,B,C,D,J,K,L,M,N,P
A,B,C,D,J,K,N
O
Property
A,B,J,K,L,M,N,O,P
A,B,J,K,L,M,N,P
A,B,J,K,N
O
Passengers
A,B,G,H,J,K,L,M,N,O,P A,B,G,H,J,K,L,M,N,P
A,B,G,H,J,K,N
O
Household Goods
A,F,K,M,N,O,P
A,F,K,M,N,P
A,F,K,N
O
Property
A,K,M,N,O,P
A,K,M,N,P
A,K,N
O
Household Goods
A,B,F,K,M,N,O,P
A,B,F,K,M,N,P
A,B,F,K,N
O
Property
A,B,K,M,N,O,P
A,B,K,M,N,P
A,B,K,N
O
Household Goods
A,K,M,N,O,P
A,K,M,N,P
A,K,N
O
Property
A,K,M,N,O,P
A,K,M,N,P
A,K,N
O
Intermodal Equipment Providers
A,B,M,N,O,P
A,B,M,N,P
A,B,N
(n/a)
Cargo Tank Facility
A,E,M,N,O,P
A,E,M,N,P
A,E,N
(n/a)
Freight Forwarder (with Vehicles) of:
Freight Forwarder (no Vehicles) of:
FORM MCSA-1 [URS-1] Page 2 of 26
OMB No.: 2126-0051
Section
A
Expiration: 11/30/2016
BUSINESS DESCRIPTION
(To be completed by all, except for those only providing
notification of transfers of operating authority registration)
1. LEGAL BUSINESS NAME:
2. DOING BUSINESS AS NAME (if different from Legal Business Name):
3. PRINCIPAL ADDRESS (Principal Place of Business) (a P.O. Box number will not be accepted):
STREET ADDRESS/ROUTE NUMBER
CITY
STATE/PROVINCE ZIP CODE + 4
P.O. Box Number:
Same as Principal Address
4. MAILING ADDRESS (this may be a P.O. Box number):
COLONIA (Mexico only) FOREIGN COUNTRY
Mailing address below:
STREET ADDRESS/ROUTE NUMBER
CITY
STATE/PROVINCE ZIP CODE + 4
COLONIA (Mexico only) FOREIGN COUNTRY
5. COUNTRY OF DOMICILE OF PRINCIPAL PLACE OF BUSINESS:
United States
Canada
Mexico
Other country
(Canadian National Safety Code Number)
(Mexican Federal Taxpayer Registry Number)
(Enter other country here)
6. PRINCIPAL BUSINESS TELEPHONE NUMBER:
7. PRINCIPAL BUSINESS FAX NUMBER (optional):
8. PRINCIPAL BUSINESS CELL PHONE NUMBER (optional):
9. USDOT NUMBER:
(if updating or if applicant otherwise
has an active USDOT number):
10. IRS TAX ID NUMBER:
(enter the Employer Identification
Number assigned to the applicant by the
Internal Revenue Service)
12. FORM OF BUSINESS (select one):
Sole Proprietor
Partnership
Limited liability company
Corporation (indicate state where incorporated):
Trust
13. OWNERSHIP and CONTROL (select one):
11. DUN & BRADSTREET NUMBER:
Limited liability partnership
Unit of state or local government
Other (please specify):
Owned/controlled by citizen of U.S.
Owned/controlled by citizen of Canada
Owned/controlled by citizen of Mexico
Owned/controlled by citizen of other foreign country:
14. NAME(S) AND TITLE(S)* OF SOLE PROPRIETOR, PARTNERS, OR OFFICERS
(*e.g., President, Treasurer, General Partner, Limited Partner):
NAME
TITLE
NAME
TITLE
NAME
TITLE
NAME
TITLE
FORM MCSA-1 [URS-1] Page 3 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
15. OPERATION CLASSIFICATION (check all that apply):
a. For-Hire Motor Carrier
Property (if checked, please specify):
Hazardous Materials
Household Goods
Exempt Commodities
Other Non-Hazardous Freight
Passengers (if checked, please specify):
Regular Route
Charter & Special Operations
Limousine/Van Operations
FTA Grantee
Mexico-Owned, U.S.-Based Enterprise (if checked, please specify):
United States-based enterprise owned or controlled by persons of Mexico providing truck services for the transportation
of international cargo (except Household Goods)
United States-based enterprise owned or controlled by persons of Mexico providing truck services for the international
transportation of Household Goods
United States-based enterprise owned or controlled by persons of Mexico transporting passengers in Charter or
Special Operations
United States-based enterprise owned or controlled by persons of Mexico providing transportation of passengers over
regular routes.
b. Private Motor Carrier
Property — Hazardous Materials
Passengers — Business
Property — Non-Hazardous Materials
Passengers — Non-Business
Migrant Workers
c. Property Broker
General Freight (except Household Goods)
Household Goods
d. Freight Forwarder
General Freight (except Household Goods)
Household Goods
e. Government Entity
f. Cargo Tank Facility
g. Intermodal Equipment Provider
h. Driveaway/Towaway
i. Other (please specify):
16. COMPANY CONTACT PERSON (please designate an
individual within your company to respond to inquiries):
17. APPLICANT'S REPRESENTATIVE (please designate an
individual to respond to inquiries, if applicable):
NAME
TITLE
NAME
TITLE
STREET ADDRESS/ROUTE NUMBER
CITY
STREET ADDRESS/ROUTE NUMBER
CITY
STATE/PROVINCE
E-MAIL ADDRESS*
STATE/PROVINCE
E-MAIL ADDRESS*
FOREIGN COUNTRY
COLONIA (Mexico only)
ZIP/POSTAL CODE
COLONIA (Mexico only)
TELEPHONE NO.
FAX NO.*
CELL PHONE NO.*
TELEPHONE NO.
(*optional field)
ZIP/POSTAL CODE
FOREIGN COUNTRY
FAX NO.*
(*optional field)
FORM MCSA-1 [URS-1] Page 4 of 26
CELL PHONE NO.*
OMB No.: 2126-0051
Expiration: 11/30/2016
18. CERTIFICATION STATEMENT (to be completed by the applicant):
I,
(please type or print name)
, certify that I am familiar with the Federal Motor Carrier Safety Regulations and, if applicable, the Federal
Hazardous Materials Regulations, and the Federal Motor Carrier Commercial Regulations. Under penalties of perjury, under the laws of the United States
of America, I certify that all information supplied on this form or relating to this application is true and correct. Further, I certify that I am qualifed and
authorized to file this application. I know that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under
18 U.S.C. § 1001 by imprisonment up to 5 years and fines up to $250,000 for each offense. Additionally, these statements are punishable as perjury under 18
U.S.C. § 1621, which provides for fines up to $250,000 or imprisonment up to 5 years for each offense.
I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State
offense involving the distribution or possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits,
either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, formerly Pub. L. 100-690, Title V, Section 5301, Nov.
18, 1988, 102 Stat. 4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002(d), Nov. 29, 1990, 104 Stat. 4827 (21 U.S.C. § 826).
Signature:
Section
B
Date:
Title:
OPERATION CLASSIFICATION AND INFORMATION
(To be completed by all motor carriers, freight forwarders with
vehicles, and intermodal equipment providers)
19. TYPE OF OPERATION (please check all that apply):
Interstate (Non-Hazardous Materials)
Interstate (Hazardous Materials)
Intrastate (Non-Hazardous Materials)
Intrastate (Hazardous Materials)
20. CARGO (please check all classifications of cargo that applicant transports or handles):
a. General Freight
k. Liquids/Gases
u. Commodities (Dry), in Bulk
b. Household Goods
l. Intermodal Containers
v. Refrigerated Food
c. Metal: Sheets, Coils, Rolls
m. Oil Field Equipment
w. Beverages
d. Motor Vehicles
n. Livestock
x. Paper Products
e. Driveaway/Towaway
o. Grain, Feed, Hay
y. Utility Service
f. Logs, Poles, Beams, Lumber
p. Coal/Coke
z. Farm Supplies
g. Building Materials
q. Meat
aa. Water Well
h. Mobile Homes
r. Garbage, Refuse, Trash
bb. Construction
i. Machinery, Large Objects
s. U.S. Mail
cc. Other (please specify):
j. Fresh Produce
t. Chemicals
21. CARRIER MILEAGE (please estimate the total number of miles, to the nearest 10,000, of commercial motor vehicle[s] operated by the
applicant [leased or owned] in the U.S. during the previous 12 months):
FORM MCSA-1 [URS-1] Page 5 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
22. (a) NUMBER OF VEHICLES WITH A GROSS VEHICLE WEIGHT RATING (GVWR), GROSS COMBINATION WEIGHT RATING (GCWR),
GROSS VEHICLE WEIGHT (GVW), OR GROSS COMBINATION WEIGHT (GCW) ≥ 10,001 POUNDS THAT ARE OPERATED (if
update) OR WILL BE OPERATING (if new application) IN THE U.S.:
Straight
Truck(s)
Truck
Tractor(s)
Trailer(s)
IEP Trailer
Chassis only
Hazmat
Cargo Tank
Truck(s)
Hazmat
Cargo Tank
Trailer(s)
Motor
Coaches
School Bus(es)
Minibus(es)
Van(s)
Limousine(s)
Number of vehicles carrying number of passengers (including the driver)
1-8
9-15
16+
16+
1-8
9-15
1-8
Owned
Term Leased
Trip Leased
Serviced
Towaway/
Driveaway*
*Persons who conduct driveaway operations do not need to provide vehicle information due to the nature of these operations.
23. (b) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW, OR GCW ≥ 10,001 POUNDS THAT ARE OPERATED OR WILL BE
OPERATING IN CANADA OR MEXICO (to be completed by U.S.-domiciled motor carriers only):
Canada:
Mexico:
23. (c) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW, OR GCW ≥ 10,001 POUNDS THAT ARE OPERATED OR WILL BE
OPERATING IN INTERSTATE COMMERCE:
Interstate:
23. (d) NUMBER OF VEHICLES WITH A GVWR, GCWR, GVW, OR GCW ≥ 10,001 POUNDS THAT ARE OPERATED OR WILL BE
OPERATING SOLELY IN INTRASTATE COMMERCE:
Solely Intrastate:
23. (a) NUMBER OF DRIVERS WHO OPERATE OR WILL BE OPERATING IN THE U.S.:
Interstate
Solely Intrastate
Total Drivers
Total Commercial Driver's
License (CDL) Drivers
Within 100 Air-Mile Radius
Beyond 100 Air-Mile Radius
24. (b) NUMBER OF DRIVERS WHO OPERATE OR WILL BE OPERATING IN CANADA OR MEXICO
(to be completed by U.S.-domiciled motor carriers only):
Canada:
Mexico:
FORM MCSA-1 [URS-1] Page 6 of 26
9-15
16+
OMB No.: 2126-0051
Section
C
Expiration: 11/30/2016
HAZARDOUS MATERIALS (HM)
(To be completed only by HM motor carriers/shippers)
24. HAZARDOUS MATERIALS CARRIED OR SHIPPED (please check all that apply):
C=Carried S=Shipped B=Bulk NB=Non-Bulk (see instructions)
a. Division 1.1 Explosives
(with mass explosion hazard)
b. Division 1.2 Explosives
(with projection hazard)
c. Division 1.3 Explosives
(with predominantly fire hazard)
d. Division 1.4 Explosives
(with no significant blast hazard)
e. Division 1.5 Very insensitive
explosives; blasting agents
f. Division 1.6 Extremely
insensitive detonating
substances
g. Division 2.1 Flammable gas
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
h. Division 2.1 Liquefied
petroleum gas (LPG)
i. Division 2.1 Methane gas
C
S
B
NB
C
S
B
NB
j. Division 2.2 Non-flammable
compressed gas
k. Division 2.2 Anhydrous
ammonia
l. Division 2.3A Poison gas
(which is Poison Inhalation
Hazard [PIH] Zone A)
m. Division 2.3B Poison gas
(which is PIH Zone B)
n. Division 2.3C Poison gas
(which is PIH Zone C)
o. Division 2.3D Poison gas
(which is PIH Zone D)
p. Class3 Flammable and
combustible liquid
q. Class3A Flammable liquid
(which is PIH Zone A)
r. Class3B Flammable liquid
(which is PIH Zone B)
s. Combustible liquid
(refer to 49 CFR § 173.20 [b])
t. Division 4.1 Flammable solid
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
u. Division 4.2 Spontaneously
combustible material
C
S
B
NB
v. Division 4.3 Dangerous when
wet material
w. Division 5.1 Oxidizer
C
S
B
NB
C
S
B
NB
x. Division 5.2 Organic peroxide
C
S
B
NB
y. Division 6.1 Poison (poisonous
C
S
B
liquid with no inhalation hazard)
z. Division 6.1 Solid (meets the
C
S
B
definition of a poisonous solid)
aa. Division 6.1A Poison liquid
C
S
B
(which is PIH Zone A)
bb. Division 6.1B Poison liquid
C
S
B
(which is PIH Zone B)
cc. Division 6.2 Infectious
C
S
B
substance (etiologic agent)
dd. Class 7 Radioactive materials
C
S
B
(other than Highway Route
Controlled Quantity of Radioactive Material [HRCQ])
ee. HRCQ
C
S
B
NB
ff. Class 8 Corrosive material
NB
NB
NB
NB
NB
NB
C
S
B
NB
gg. Class 8A Corrosive liquid
(which is PIH Zone A)
hh. Class 8B Corrosive liquid
(which is PIH Zone B)
ii. Class 9 Miscellaneous
hazardous material
jj. Elevated temperature material
(meets definition in 49 CFR § 171.8
of an elevated temperature material)
C
S
B
NB
C
S
B
NB
C
S
B
NB
C
S
B
NB
kk. Infectious waste
(meets definition in 49 CFR § 171.8
of an infectious waste)
C
S
B
NB
ll. Marine pollutants
(meets definition in 49 CFR § 171.8
of a marine pollutant)
C
S
B
NB
mm. Hazardous substances (RQ)
C
S
B
(meets definition in 49 CFR § 171.8
of a reportable quantity of a hazardous substance)
NB
nn. Hazardous waste
(meets definition in 49 CFR § 171.8
of a hazardous waste)
C
S
B
NB
oo. Other regulated material
(meets definition in 49 CFR § 171.8
of Other Regulated Material)
C
S
B
NB
FORM MCSA-1 [URS-1] Page 7 of 26
OMB No.: 2126-0051
Section
D
Expiration: 11/30/2016
HAZARDOUS MATERIALS PERMITTING
(To be completed only by HM motor carriers applying for a hazardous
materials safety permit under 49 CFR part 385, subpart E)
25. WHICH OF THE FOLLOWING HAZARDOUS MATERIALS DOES YOUR COMPANY TRANSPORT? (please check all that apply):
Highway Route Controlled Quantities (HRCQ) of radioactive materials
More than 25 kilograms (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 packaging that has a 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 liters (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 liters (3,500 gallons).
26. IF YOU CHECKED ANY ITEM IN QUESTION 24, ARE YOU APPLYING FOR OR RENEWING A HAZARDOUS MATERIAL SAFETY
PERMIT? (select one):
Initial
Renewal
27. IF YOUR COMPANY DOES NOT HAVE A USDOT NUMBER, HOW MANY ACCIDENTS, AS DEFINED IN 49 CFR 390.5, HAS YOUR
COMPANY HAD IN THE PAST 12 MONTHS? (select one):
Not applicable
No USDOT Number/Number of Accidents:
28. DOES YOUR COMPANY CERTIFY THAT IT HAS A SATISFACTORY SECURITY PROGRAM IN PLACE AS REQUIRED IN 49 CFR PART
385, SUBPART E? (select one):
Yes
No
29. IS YOUR COMPANY REQUIRED BY ANY STATE TO HAVE A PERMIT FOR ANY OF THE HAZARDOUS MATERIALS LISTED IN
QUESTION 24? (select one):
Yes
No
30. IF YOUR ANSWER TO QUESTION 29 IS YES, CHECK THE STATES IN WHICH YOU HAVE THE PERMIT (please check all that apply):
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.
FORM MCSA-1 [URS-1] Page 8 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
31. CERTIFICATION STATEMENT (to be completed by an authorized official):
I,
, certify that I am familiar with the Federal Hazardous Materials Regulations. Under penalties of perjury,
(please type or print name)
under the laws of the United States of America, I certify that all information entered on this report is, to the best of my knowledge and belief, true, correct,
and complete.
Signature:
Section
E
Date:
Title:
CARGO TANK FACILITY
(To be completed by applicants registering as cargo
tank facilities under 49 CFR part 107, subpart F)
32. PLEASE REFER TO INSTRUCTIONS FOR SECTION E TO COMPLETE THE FOLLOWING INFORMATION FOR EACH CARGO
TANK FACILITY BEING REGISTERED (please check all that apply):
FUNCTIONS
EXEMPTIONS/
SPECIAL PERMITS
VEHICLES
External Visual Inspection
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Internal Visual Inspection
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Leakage Test
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Lining Inspection
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Thickness Test
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Pressure Test
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
MC331
MC338
Manufacture
DOT406
DOT407
DOT412
Assembly
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
R
epair (non-American
Society of Mechanical
Engineers [ASME])
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
R
epair (ASME)
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
C
ertification (Design
Certified Engineer)
MC306
MC307
MC312
MC330
MC331
MC338
DOT406
DOT407
DOT412
MC300
MC301
MC302
MC303
MC304
MC305
MC310
MC311
Component Manufacture
MOBILE TESTING INFORMATION
Where do you use testing/inspection equipment?
None
Fixed Facility
FORM MCSA-1 [URS-1] Page 9 of 26
Mobile
Both
OMB No.: 2126-0051
Expiration: 11/30/2016
PROCESS AGENT (to be completed if the registrant
is not a resident of the United States):
RESPONSIBLE PERSON
(facility location):
NAME
NAME
STREET ADDRESS/ROUTE NUMBER (no P.O. Box)
TITLE
E-MAIL ADDRESS
TELEPHONE NO.
FAX NO.
CITY
STATE/PROVINCE
ZIP/POSTAL CODE
DESIGN CERTIFIED ENGINEERS/REGISTERED INSPECTORS/AUTHORIZED INSPECTORS EMPLOYED BY THE COMPANY:
NAME
TYPE
STREET ADDRESS/ROUTE NUMBER
TYPE
CITY
STATE/PROVINCE
ZIP/POSTAL CODE
NON-EMPLOYEE DESIGN CERTIFIED ENGINEERS/REGISTERED INSPECTORS/AUTHORIZED INSPECTORS:
NAME
CARGO TANK #
TYPE
COMPANY
STREET ADDRESS/ROUTE NUMBER
CARGO TANK #
TYPE
COMPANY
CITY
STATE/PROVINCE
ZIP/POSTAL CODE
ASME "U" STAMP OR NBCA "R" STAMP:
STAMP TYPE
CERTIFICATION #
AUTHORIZATION DATE
EXPIRATION DATE
STAMP TYPE
CERTIFICATION #
AUTHORIZATION DATE
EXPIRATION DATE
I,
(please type or print name)
, certify that all Registered Inspectors and Design Certifying Engineers used in performance of the
prescribed functions meet the minimum qualification requirements set forth in 49 CFR 171.8, that I am the person responsible for ensuring compliance
with the applicable requirements of this chapter, and that I have knowledge of the requirements applicable to the functions to be performed.
Under penalty of perjury, under the laws of the United States of America, I declare that the information entered on this report is, to the best of my
knowledge and belief, true, correct and complete.
Signature:
Date:
FORM MCSA-1 [URS-1] Page 10 of 26
Title:
OMB No.: 2126-0051
Section
F
Expiration: 11/30/2016
TRANSPORTATION OF HOUSEHOLD GOODS
(To be completed by household goods motor carriers, household
goods brokers, and household goods freight forwarders)
33. CERTIFICATION: ARBITRATION PROGRAM AND TARIFF
Motor Carrier of Household Goods (including United States-based enterprises transporting international household goods shipments):
I,
(please type or print name)
, certify that I am fit, willing, and able to provide the specialized services necessary to transport household
goods. I am familiar with FMCSA regulations for household goods movements and have acquired or am willing to acquire the protective equipment and
trained operators necessary to perform household goods movements. I certify that my tariff is available for inspection by shippers upon reasonable request.
I further certify that I will offer arbitration as a means of settling loss and damage disputes and disputes regarding carrier charges in addition to those
collected at delivery. The following information can be used to contact a representative of the arbitration program in which I will participate.
Contact information for the
arbitration program in which I will participate:
(name)
Signature:
(address)
Date:
(telephone number)
Title:
Broker of Household Goods
I,
(please type or print name)
, certify that applicant is fit, willing, and able to provide household goods brokerage operations and to
comply with all pertinent statutory and regulatory requirements.
Signature:
Date:
Title:
Freight Forwarder of Household Goods
I,
(please type or print name)
, certify that applicant is fit, willing, and able to provide household goods freight-forwarding operations and
to comply with all pertinent statutory and regulatory requirements.
Signature:
Date:
Title:
Household Goods Motor Carrier Applicants Must:
1. Provide evidence of participation in an arbitration program and a copy of the notice they provide to shippers of the availability of binding arbitration.
2. Identify their tariff and provide a copy of the notice to shippers of the availability of that tariff for inspection, indicating how that notice is provided.
Signature:
Date:
FORM MCSA-1 [URS-1] Page 11 of 26
Title:
OMB No.: 2126-0051
Section
G
Expiration: 11/30/2016
TRANSPORTATION OF PASSENGERS
(To be completed by passenger carriers)
34. GOVERNMENT FUNDING STATUS — Specify the nature of governmental financial assistance you receive, if any, by checking the
appropriate button (check only one):
Public recipient — Applicant is any of the following: any State; any municipality or other political subdivision of a State; any public
agency or instrumentality of such entities of one or more State(s); an Indian tribe; and any corporation, board or other person owned
or controlled by such entities or owned by, controlled by, or under common control with such a corporation, board, or person which is
receiving or has ever received governmental financial assistance for the purchase or operation of any bus.
Private recipient — Applicant is not a public recipient but is receiving, or has received in the past, governmental financial assistance in
the form of a subsidy for the purchase, lease or operation of any bus.
Non-recipient — Applicant is not receiving, or using equipment acquired with, governmental financial assistance.
Public Interest Criteria: Regular route public recipient and charter and special operations private recipient applicants may introduce
supplemental evidence describing how the proposed service will respond to existing transportation needs or is otherwise consistent
with the public interest. Filing this evidence with the application is optional, but it may be needed later, if the application is protested.
Public Recipient Applicants: All public recipient applicants for charter or special transportation must submit evidence to demonstrate
either that:
(1) No motor carrier of passengers (other than a motor carrier of passengers that is a public recipient of governmental assistance) is
providing, or is willing and able to provide, the transportation to be authorized by the certificate; or
(2) The transportation to be authorized by the certificate is to be provided entirely in the area in which the public recipient provides
regularly scheduled mass transportation services.
Supplemental evidence should be scanned and uploaded along with your application.
Fitness Only Criteria: No additional evidence is needed from applicants for regular-route or charter and special transportation that do
not receive governmental financial assistance.
35. PASSENGER CARRIER COMPLIANCE CERTIFICATION:
I,
(please type or print name)
, certify that I am fit, willing, and able to comply with all pertinent statutory and regulatory requirements
including the U.S. Department of Transportation’s Americans with Disabilities Act regulations for over-the-road bus companies located at 49 CFR Part 37,
Subpart H, if applicable.
Signature:
Date:
Title:
Private entities that are primarily in the business of transporting people, whose operations affect commerce, and that transport passengers in an over-theroad bus (defined as a bus characterized by an elevated passenger deck over a baggage compartment) are subject to the U.S. Department of Transportation’s
Americans with Disabilities Act regulations, located at 49 CFR Part 37, Subpart H. The term charter and special transportation corresponds to the term
“demand responsive service,” and “service over regular routes,” corresponds to the term “fixed route service” under the Americans with Disabilities Act
regulations for over-the-road bus companies located at 49 CFR Part 37, Subpart H. For a general overview of these regulations, please refer to the Federal
Motor Carrier Safety Administration’s website at www.fmcsa.dot.gov.
FORM MCSA-1 [URS-1] Page 12 of 26
OMB No.: 2126-0051
Section
H
Expiration: 11/30/2016
SCOPE OF AUTHORITY
(To be completed by passenger carriers)
36. ALL PASSENGER CARRIER APPLICANTS MUST COMPLETE THIS SECTION (check all that apply):
1. Charter and special transportation, in interstate or foreign commerce, between points in the United States.
2. C
harter and special transportation, in interstate or foreign commerce, between points in the United States, provided by United
States-based enterprises owned or controlled by persons of Mexico.
3. S ervice as a passenger carrier over regular routes. (Regular route passenger carrier authority to perform regularly scheduled
service.) Regular route passenger service includes authority to transport newspapers, baggage of passengers, express packages,
and mail in the same motor vehicle with passengers, or baggage of passengers in a separate motor vehicle. Public recipient
applicants requesting authority to operate over regular routes must scan and upload to the application a description of the specific
routes over which you intend to provide regularly scheduled service. You must also furnish a map clearly identifying each
regular route involved in your passenger carrier service description(s).
4. S ervice as a passenger carrier over regular routes provided by United States-based enterprises owned or controlled by persons
of Mexico. Regular route passenger service includes authority to transport newspapers, baggage of passengers, express
packages, and mail in the same motor vehicle with passengers, or baggage of passengers in a separate motor vehicle.
5. A
re you also requesting intrastate authority to provide the service described in item 3 or 4?
Yes
No
NOTE: The FMCSA has no jurisdiction to grant intrastate authority
independently of interstate regular route authority. No carrier may conduct
operations under a certificate authorizing intrastate regular route service
unless it actually is conducting substantial operations in interstate
commerce over the same route(s).
Section
I
COMMERCIAL ZONE OPERATIONS
(To be completed by Mexico-domiciled motor carriers operating
exclusively within U.S.-Mexico international border commercial zones)
“Within U.S.-Mexico International Border Commercial Zones” refers to service in the United
States entirely within the commercial zone of a municipality that is adjacent to Mexico. A
Mexico-domiciled motor carrier may not provide point-to-point transportation services, including
express delivery services, within the United States for goods other than international cargo.
37. SCOPE OF REGISTRATION (check all that apply):
Service as a for-hire motor carrier of property (except household goods) within the commercial zones.
Service as a for-hire motor carrier of household goods within the commercial zones.
Service as a private motor carrier of property (handling applicant’s own goods) within the commercial zones.
Service as a passenger motor carrier within the commercial zones.
38. UNITED STATES ADDRESS:
(a) Do you currently maintain an office in the United States?
Yes
No
(b) If yes, please provide the full street address, telephone number, and fax number:
STREET ADDRESS/ROUTE NUMBER
CITY
STATE
ZIP CODE + 4
FORM MCSA-1 [URS-1] Page 13 of 26
TELEPHONE NUMBER FAX NUMBER
OMB No.: 2126-0051
Section
J
Expiration: 11/30/2016
NON-NORTH AMERICA-DOMICILED CARRIERS
(To be completed by motor carriers not domiciled in
the United States, Mexico, or Canada)
“Non-North America-domiciled” refers to an applicant whose principal place of business is located
outside of the United States, Mexico, or Canada and is seeking to provide the following transportation
service in foreign commerce:
39. SCOPE OF REGISTRATION (check all that apply):
Transportation of property by a non-North America-domiciled motor carrier between points outside of the United States and all
points in the United States.
Transportation of passengers by a non-North America-domiciled carrier providing charter and tour bus operations between points
outside of the United States and all points in the United States.
Transportation of passengers by a non-North America-domiciled private motor carrier between points outside of the United States
and all points in the United States.
40. INDICATE THE PRINCIPAL BORDER CROSSING POINTS THAT APPLICANT INTENDS TO UTILIZE:
41. UNITED STATES ADDRESS:
(a) Do you currently maintain an office in the United States?
Yes
No
(b) If yes, please provide the full street address, telephone number, and fax number:
STREET ADDRESS/ROUTE NUMBER
CITY
STATE
ZIP CODE + 4
FORM MCSA-1 [URS-1] Page 14 of 26
TELEPHONE NUMBER FAX NUMBER
OMB No.: 2126-0051
Section
K
Expiration: 11/30/2016
ADDITIONAL INFORMATION
(To be completed by for-hire motor carriers and private hazardous materials carriers, including
those domiciled in Mexico and outside of North America, and by brokers and freight forwarders)
If applicant is a Mexico-domiciled motor carrier of property and operates exclusively within the U.S.-Mexico border
commercial zones, please skip to item 43(f), under this section.
42. FINANCIAL RESPONSIBILITY (check all that apply):
(a) Motor Passenger Carrier
For-hire motor passenger carriers operating in the United States, including Mexico-domiciled motor passenger carriers, must
maintain public liability insurance. The minimum amount of coverage is shown in parentheses.
Applicant has one or more vehicles with a seating capacity of 16 passengers or more, including the driver* ($5,000,000 U.S.)
Applicant has only motor vehicles with a seating capacity of 15 passengers or fewer, including the driver* ($1,500,000 U.S.)
*unless exempted under 49 CFR 387.27(b)
Applicant receives a grant from the Federal Transit Administration (FTA) under 49 U.S.C. §§ 5307, 5310, or 5311. Applicant
understands that it is not required to comply with FMCSA’s minimum levels of public liability insurance, and that applicant is
required to maintain financial responsibility at the highest level required by any State within which it operates (transit service
area) (see 49 U.S.C. § 31138[e][4]).
Applicant's transit service area lies within the borders of the following State(s):
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
Applicant will maintain financial responsibility in the amount of $
Applicant's insurance company
has filed
will file proof of liability insurance coverage.
NOTE: Grantees under 49 U.S.C. §§ 5307, 5310, or 5311 that file evidence of
State-prescribed financial responsibility limits that are lower than the Federal
limits will be registered to provide interstate service within their designated
transit service area only.
(b) Motor Property Carrier
Applicant will operate motor vehicles having a gross vehicle weight rating (GVWR) or gross combination weight rating (GCWR)
of 10,001 pounds (4,536 kg) or more to transport:
Non-hazardous commodities ($750,000 U.S.)
Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(c) ($1,000,000 U.S.)
Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(b) ($5,000,000 U.S.)
Applicant will only operate motor vehicles having a gross vehicle weight under 10,001 pounds (4,536 kg) to transport:
Any quantity of Divisions 1.1, 1.2 or 1.3 explosives, any quantity of poison gas (Division 2.3, Hazard Zone A or Division 6.1,
Packing Group 1, Hazard Zone A materials), or highway route-controlled quantity radioactive materials as defined in 49 CFR
173.455 ($5,000,000 U.S.)
Commodities other than those listed above ($300,000 U.S.)
Applicant will maintain cargo insurance (HHG motor carriers only) ($5,000 / $10,000 U.S.)
FORM MCSA-1 [URS-1] Page 15 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
42. FINANCIAL RESPONSIBILITY (continued):
(c) Property Broker
Applicant's surety company/financial institution
has filed
will file a property broker’s surety bond or trust fund
agreement in the amount of $10,000 (general
freight) or $25,000 (household goods).
(d) Self-Insured Carriers/Freight Forwarders
Applicant has received authorization from FMCSA to self-insure its:
Bodily Injury and Property Damage (BI&PD) liability
Cargo liability
and applicant is in full compliance with the conditions of the Agency’s decision authorizing it to self-insure.
Yes
No
(e) Freight Forwarder
Applicant will operate as a freight forwarder only and seeks a waiver of BI&PD liability requirements by certifying that in its
forwarding operations it: (1) will not own or operate any motor vehicles upon highways in the transportation of property; (2)
will not perform transfer, collection, or delivery services; and (3) will not have motor vehicles operated under its direction and
control in the performance of transfer, collection, or delivery services
Applicant will operate vehicles having Gross Vehicle Weight Ratings (GVWR) of 10,001 pounds or more to transport:
Non-hazardous commodities ($750,000 U.S.)
Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(c) ($1,000,000 U.S.)
Hazardous materials referenced in the FMCSA regulations at 49 CFR 387.303(b)(2)(b) ($5,000,000 U.S.)
Applicant will operate only vehicles having Gross Vehicle Weight Ratings (GVWR) under 10,001 pounds to transport:
Any quantity of Classes A or B explosives, any quantity of poison gas (Poison A), or highway route controlled quantity of
radioactive materials ($5,000,000 U.S.)
Commodities other than those listed above ($300,000 U.S.)
Applicant will maintain cargo insurance (HHG freight forwarders only) ($5,000 / $10,000 U.S.)
(f) Motor Carriers Domiciled in Mexico Only
Has applicant operated, or does applicant currently operate, under insurance issued by an insurance or surety company in amounts
meeting FMCSA minimum financial responsibility requirements for periods of 24 hours or longer for movements in the U.S.-Mexico
Yes
No
international border commercial zones? (See 49 CFR 387.303[b][4])
(g) Insurance Information (Proof of insurance will be mandatory before registration/operating authority registration can be finalized but
this insurance information need not be completed at time of the initial MCSA-1 Form submission.)
Applicant must maintain insurance coverage for bodily injury and property damage. Please provide the following information:
Insurance Company:
INSURANCE COMPANY
MAXIMUM INSURANCE AMOUNT
STREET ADDRESS/ROUTE NUMBER
POLICY NUMBER
CITY
DATE ISSUED
STATE/PROVINCE
ZIP/POSTAL CODE
INSURANCE EFFECTIVE DATE
EXPIRATION DATE
Self-Insured:
BI&PD liability up to: $
Cargo liability up to: $
FORM MCSA-1 [URS-1] Page 16 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
43. AFFILIATION WITH FMCSA-LICENSED ENTITIES OR OTHER APPLICANTS APPLYING FOR USDOT NUMBER REGISTRATION
Do you currently have, or have you had within the last 3 years of the date of filing this application, relationships involving common
stock, common ownership, common management, common control or familial relationships with any FMCSA-regulated entities?
Yes
No
If yes, provide the name(s) of the company, USDOT Number, MC/FF/MX number, and the company’s latest U.S. DOT safety rating.
Applicant must indicate whether these entities are currently disqualified from operating commercial motor vehicles anywhere in the
United States pursuant to section 219 of the Motor Carrier Safety Improvement Act of 1999 (MCSIA) (Public Law 106-159, 113 Stat.
1748 (Dec. 9, 1999)).
Section
L
USDOT NUMBER
MC/FF/MX
NUMBER
LEGAL NAME
DBA NAME
CURRENT
SAFETY RATING
REVOKED
USDOT NUMBER
MC/FF/MX
NUMBER
LEGAL NAME
DBA NAME
CURRENT
SAFETY RATING
REVOKED
USDOT NUMBER
MC/FF/MX
NUMBER
LEGAL NAME
DBA NAME
CURRENT
SAFETY RATING
REVOKED
SAFETY CERTIFICATIONS
(To be completed by Mexico-domiciled and
non-North America-domiciled motor carriers)
44. SAFETY CERTIFICATIONS FOR MEXICO-DOMICILED AND NON-NORTH AMERICA-DOMICILED CARRIERS
(a) Applicant maintains current copies of all U.S. DOT Federal Motor Carrier Safety Regulations, Federal Motor
Vehicle Safety Standards and if applicable the Federal Hazardous Materials Regulations (if a property carrier
transporting hazardous materials), and Federal Motor Carrier Commercial Regulations, understands and will
comply with such regulations, and has ensured that all company personnel are aware of these requirements.
Yes
No
(b) I ndividual responsible for compliance with applicable regulatory and safety requirements.
FULL NAME
POSITION/TITLE
STREET ADDRESS/ROUTE NUMBER
CITY
STATE
ZIP CODE
(c) A
pplicant certifies that the following tasks and measures will be fully accomplished and procedures fully implemented before it
commences interstate operations in the United States:
I. Driver Qualifications
1. The carrier has in place a system and procedures for ensuring the continued qualification of drivers to
operate safely, including a safety record for each driver, procedures for verification of proper age and
licensing of each driver, and procedures for identifying drivers who are not complying with the U.S. safety
regulations, and a description of a retraining and educational program for poorly performing drivers.
2. The carrier has procedures in place to review drivers’ employment and driving histories for at least the last
three years, to determine whether the individual is qualified and competent to drive safely.
3. The carrier has established a program to review the records of each driver at least once every twelve (12)
months and will maintain a record of the review.
4. The carrier will ensure, once operations in the United States have begun, that all of its drivers operating in
the United States are at least 21 years of age and possess a valid Commercial Driver’s License or a valid
Licencia Federal de Conductor (LFC) and that the driver’s LFC is registered in Mexican Government’s
Secretaria de Communicaciones y Transportes SCT (Ministry of Communications and Transport) database.
II. Hours-Of-Service
1. The carrier has in place a record keeping system and procedures to monitor the hours-of-service
performed by drivers, including procedures for continuing review of drivers’ log books, and for ensuring
compliance with all operations requirements.
FORM MCSA-1 [URS-1] Page 17 of 26
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
OMB No.: 2126-0051
Expiration: 11/30/2016
II. Hours-Of-Service (continued)
2. The carrier has ensured that all drivers to be used in the United States are knowledgeable of the United
States’ hours-of-service requirements, and has clearly and specifically instructed drivers about the
application to them of the 11-hour, 14-hour, and 60- and 70-hour rules, as well as the requirement for
preparing daily log entries in their own handwriting for each 24-hour period.
3. The carrier has attached, as Attachment F to this application, statements describing the carrier’s
monitoring procedures to ensure that its drivers complete logbooks correctly, and describing the carrier’s
record keeping and driver review procedures.
4. The carrier will ensure, once operations in the United States have begun, that its drivers operate within
the hours-of-service rules and are not fatigued while on duty.
III. Drug and Alcohol Testing (to be completed by motor carriers subject to drug and alcohol testing only)
Yes
No
Yes
No
Yes
No
1. The carrier is familiar with the alcohol and controlled substance testing requirements of 49 CFR part 382
and 49 CFR part 40 and has in place a program for systematic testing of drivers.
2. The carrier has attached, as Attachment A to this application, the name, address, and telephone number
of the person(s) responsible for implementing and overseeing alcohol and drug programs and the name,
address and telephone number of the drug testing laboratory and alcohol testing services that are used
by the company.
IV. Vehicles
Yes
No
Yes
No
1. The carrier has established a system and procedures for inspection, repair and maintenance of its
vehicles in a safe condition, and for preparation and maintenance of records of inspection, repair, and
maintenance in accordance with the U.S. DOT’s Federal Motor Carrier Safety Regulations and, if applicable,
the Federal Hazardous Materials Regulations and the Federal Commercial Regulations.
2. The carrier has inspected all vehicles that will be usd in the United States before the beginning of such
operations and has proof of the inspection on board the vehicle as required by 49 CFR 396.17.
3. The
carrier will ensure, once operations in the United States have begun, that all vehicles it operates in the
United States were manufactured or have been retrofitted in compliance with the applicable U.S. DOT
Federal Motor Vehicle Safety Standards or Canadian Motor Vehicle Safety Standards in effect at the time
of manufacture.
4. The carrier will ensure, once operations in the United States have begun, that all violations and defects noted
on inspection reports are corrected before vehicle and drivers are permitted to enter the United States.
5. (To be completed by Non-North American-domiciled carriers only.) The carrier will ensure that all vehicles
operated in the United States are inspected at least every 90 days by a certified inspector in accordance
with the requirements for a Leve l1 Inspection under the criteria of the North American Standard
Inspection, as defined in 49 CFR 350.105, once operations in the United States begin and until such time
as the carrier has held permanent registration from the FMCSA for at least 36 consecutive months. After
the 36-month period expires, the carrier will ensure that all vehicles operated in the United States are
inspected in accordance with 49 CFR 396.17 at least once every 12 months thereafter.
V. Accident Monitoring
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1. The carrier has in place a program for monitoring vehicle accidents and it maintains an accident register in
accordance with 49 CFR 390.15.
2. The carrier has attached, as Attachment B to this application, a copy of its accident register for the
previous 12 months, or a description of how the company will maintain this register once it begins
operations in the United States.
3. The carrier has established an accident countermeasures program and driver training program to reduce
accidents.
4. The carrier has attached, as Attachment C to this application, a description and explanation of the
accident monitoring program it has implemented for its operations in the United States.
VI. Production of Records
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
1. The carrier can and will produce records demonstrating compliance with the safety requirements within
48 hours of receipt of a request from a representative of the U.S. DOT/FMCSA or other authorized Federal
or State official.
2. The carrier is including as Attachment D to this application the name, address, and telephone number of
the employee to be contacted for requesting records.
FORM MCSA-1 [URS-1] Page 18 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
VII. Hazardous Materials (to be completed by motor carriers of hazardous materials only)
1. The HM carrier has full knowledge of the U.S. DOT Hazardous Materials Regulations, and has established
programs for the thorough training of its personnel as required under 49 CFR part 172, Subpart H, and
49 CFR 177.816. The HM carrier has attached, as Attachment E to this application, a statement providing
information concerning: (1) the names of employees responsible for ensuring compliance with HM
regulations; (2) a description of their HM safety functions; and (3) a copy of the information used to
provide HM training.
2. The carrier has established a system and procedures for inspection, repair and maintenance of its reusable
hazardous materials packages (cargo tanks, portable tanks, cylinders, intermediate bulk containers, etc.) in a
safe condition, and for preparation and maintenance of records of inspection, repair and maintenance in
accordance with the U.S. DOT Hazardous Materials Regulations.
3. The HM carrier has established a system and procedures for filing and maintaining HM shipping
documents.
4. The HM carrier has a system in place to ensure that all HM trucks are marked and placarded as required by
49 CFR part 172, subparts D and F.
5. The carrier will register under 49 CFR part 107, subpart G, if transporting any quantity of hazardous
materials requiring the vehicle to be placarded.
6. (To be completed by cargo tank [CT] motor carriers of hazardous materials.) The carrier submits with this
application certficates of compliance for each cargo tank the company utilizes in the U.S., together with
the name, qualifications, CT Facility number, and CT Facility number registration statement of the facility it
will be utilizing to conduct the test and inspections of such tanks as required by 49 CFR part 180.
Section
M
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
COMPLIANCE CERTIFICATIONS
(To be completed by motor carriers, brokers, cargo tank facilities,
intermodal equipment providers, and freight forwarders)
45. B
Y SIGNING THESE CERTIFICATIONS, THE CERTIFYING OFFICIAL IS ON NOTICE THAT THE REPRESENTATIONS MADE
HEREIN ARE SUBJECT TO VERIFICATION THROUGH INSPECTIONS IN THE UNITED STATES AND THROUGH THE REQUEST
FOR EXAMINATION OF RECORDS AND DOCUMENTS. FAILURE TO SUPPORT THE REPRESENTATIONS CONTAINED IN
THIS APPLICATION COULD FORM THE BASIS OF A PROCEEDING TO ASSESS CIVIL PENALTIES AND/OR LEAD TO THE
REVOCATION OF THE AUTHORITY GRANTED.
1. Applicant is willing and able to provide the proposed operations or service and to comply with all pertinent
statutory and regulatory requirements and regulations issued or administered by the U.S. Department of
Transportation, including operational regulations, safety fitness requirements, motor vehicle safety standards
and minimum financial responsibility and designation of process agent requirements.
2. Applicant is willing and able to produce for review or inspection documents which are requested for the
purpose of determining compliance with applicable statutes and regulations administered by the Department
of Transportation, including the Federal Motor Carrier Safety Regulations, Federal Motor Vehicle Safety
Standards, Commercial Regulations, Hazardous Materials Regulations, and Americans With Disabilities
Act regulations within 48 hours of any written request. Applicant understands that the written request for
documents may be served on the contact person identified on Page 4 (Section A, Item No. 18), or the designated
process agent.
3. Is applicant presently disqualified from operating commercial motor vehicles in the United States?
4. Applicant understands that the agent(s) for service of process designated on FMCSA Form BOC-3 will
be deemed applicant’s official representative(s) in the United States for receipt of filings and notices in
administrative proceedings under 49 U.S.C. § 13303, and for receipt of filings and notices issued in connection
with the enforcement of any Federal statutes or regulations.
5. Applicant is not prohibited from filing this application because its FMCSA registration is currently under
suspension, or was revoked less than 30 days before the filing of this application.
To be completed only by a Non-North America-Domiciled Motor Carrier:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
6. Applicant is willing and able to have all vehicles operated in the United States inspected at least every 90
days by a certified inspector and have decals affixed attesting to satisfactory compliance with applicable
inspection criteria. This requirement will end after applicant has held permanent registration from FMCSA for
three consecutive years.
7. If applicant’s registration has been revoked, the deficiencies cited in the revocation proceeding have been
corrected. Applicant is providing an explanation of how it has corrected these deficiencies and how it will
otherwise ensure that basic safety management controls are maintained.
Yes
No
Yes
No
FORM MCSA-1 [URS-1] Page 19 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
To be completed only by a Mexico-Domiciled Motor Carrier:
8. Applicant has paid all taxes owed under section 4481 of the U.S. Internal Revenue Service (26 U.S.C. § 4481)
for the most recent taxable period as defined under section 4482(c) of the Internal Revenue Code.
Signature:
Date:
Yes
Title:
All motor carriers operating within the United States, including foreign-domiciled motor carriers applying for USDOT registration by this form, must
comply with all applicable 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 an OSHA State plan
agency pursuant to section 18 of the Occupational Safety and Health Act of 1970. 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.
Section
N
APPLICANT'S OATH
(To be completed by applicant's authorized official)
46. THIS OATH APPLIES TO ALL SUPPLEMENTAL FILINGS TO THIS APPLICATION. (The signature must be that of an authorized official
of the applicant, not the legal representative.)
I,
(please type or print name)
, verify under penalty of perjury, under the laws of the United States of America, that all information
supplied on this form or relating to this application is true and correct. Further, I certify that I am qualified and authorized to file this application. I know
that willful misstatements or omissions of material facts constitute Federal criminal violations punishable under 18 U.S.C. § 1001 by imprisonment of up to
5 years and fines up to $250,000 for each offense. Additionally these statements are punishable as perjury under 18 U.S.C. § 1621, which provides for fines of
up to $250,000 or imprisonment of up to 5 years for each offense.
I further certify under penalty of perjury, under the laws of the United States, that I have not been convicted, after September 1, 1989, of any Federal or State
offense involving the distribution of possession of a controlled substance, or that if I have been so convicted, I am not ineligible to receive Federal benefits,
either by court order or operation of law, pursuant to Section 5301 of the Anti-Drug Abuse Act of 1988, formerly Pub. L. 100-690, Title V, Section 5301, Nov.
18, 1988, 102 Stat. 4310, renumbered and amended Pub. L. 101-647, Title X, Section 1002 (d), Nov. 29, 1990, 104 Stat. 4827 (21 U.S.C. 862).
Signature:
Date:
FORM MCSA-1 [URS-1] Page 20 of 26
Title:
No
OMB No.: 2126-0051
Section
O
Expiration: 11/30/2016
NOTIFICATION OF TRANSFERS OF
OPERATING AUTHORITY REGISTRATION
TRANSFEREE
TRANSFEROR
47. LEGAL BUSINESS NAME
55. LEGAL BUSINESS NAME
48. DOING BUSINESS AS NAME (if different from Legal Business Name)
56. DOING BUSINESS AS NAME (if different from Legal Business Name)
49. PRINCIPAL ADDRESS (PRINCIPAL PLACE OF BUSINESS)
(a P.O. Box will not be accepted)
57. PRINCIPAL ADDRESS (PRINCIPAL PLACE OF BUSINESS)
(a P.O. Box will not be accepted)
STREET ADDRESS
CITY
STREET ADDRESS
CITY
STATE/PROVINCE
ZIP CODE + 4
STATE/PROVINCE
ZIP CODE + 4
COLONIA (Mexico only)
FOREIGN COUNTRY
COLONIA (Mexico only)
FOREIGN COUNTRY
50. MAILING ADDRESS (this may be a P.O. Box number)
Same as Principal Address:
Yes
58. MAILING ADDRESS (this may be a P.O. Box number)
Same as Principal Address:
No
Yes
No
STREET ADDRESS
CITY
STREET ADDRESS
CITY
STATE/PROVINCE
ZIP CODE + 4
STATE/PROVINCE
ZIP CODE + 4
COLONIA (Mexico only)
FOREIGN COUNTRY
COLONIA (Mexico only)
FOREIGN COUNTRY
51. PRINCIPAL BUSINESS TELEPHONE NUMBER
59. PRINCIPAL BUSINESS TELEPHONE NUMBER
52. PRINCIPAL BUSINESS FAX NUMBER (optional)
60. PRINCIPAL BUSINESS FAX NUMBER (optional)
53. PRINCIPAL BUSINESS CELL PHONE NUMBER (optional)
61. PRINCIPAL BUSINESS CELL PHONE NUMBER (optional)
54. USDOT NUMBER (if the transferee does not have an active USDOT
Number, it must complete the entire MCSA-1 Form)
Applicant has active USDOT Number:
Yes
No
62. USDOT NUMBER
Applicant has active USDOT Number:
If yes, enter USDOT Number here:
If yes, enter USDOT Number here:
FORM MCSA-1 [URS-1] Page 21 of 26
Yes
No
OMB No.: 2126-0051
Section
P
Expiration: 11/30/2016
FILING FEE INFORMATION
(FMCSA does not refund filing fees)
63. TYPE OF FILING (check all that apply):
New Registration
Reinstatement
Other (no fee)
For-Hire (except FTA grantees)
For-Hire (except FTA grantees)
FTA grantee
Motor Private Carrier
Motor Private Carrier
All Other
Freight Forwarder
Freight Forwarder
Broker
Broker
Intermodal Equipment Provider
Intermodal Equipment Provider
Cargo Tank Facility
Cargo Tank Facility
Total Number of New Registration Boxes Checked:
Total Number of Reinstatement Boxes Checked:
× $300 = $
× $10 = $
FILING FEE TOTAL: $
METHOD OF PAYMENT (check one):
ELECTRONIC FUNDS TRANSFER (EFT)
BANK ROUTING NUMBER (nine digits)
BANK NAME
CHECKING ACCOUNT NUMBER
VISA
MASTERCARD
CREDIT CARD NUMBER (sixteen digits)
TYPE OR PRINT NAME OF CARD OWNER
DISCOVER
,
CARD EXPIRATION DATE (month, year)
AMERICAN EXPRESS
CARD SECURITY CODE (three digits)
SIGNATURE OF CARD OWNER
,
DATE APPLICATION WAS COMPLETED (month, day, year)
FEE POLICY:
• FMCSA does not refund filing fees.
• Your filing fees must be payable to the Federal Motor Carrier Safety Administration, by Electronic Funding Transfer, or by an approved credit card.
• Electronic Funding Transfers must be from an account in a bank in the United States.
• Fees are required for each type of registration requested. Applicant may select more than one type of registration on a single Form MCSA-1 and
submit a single payment for the total fees due. For example, if applicant wishes to be registered as both a motor carrier and a broker, applicant
may file a single Form MCSA-1 and make a single payment of $600.
• FMCSA will not process an applicant’s Form MCSA-1 until the payment has been deducted from his/her banking or credit card account.
FORM MCSA-1 [URS-1] Page 22 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
Attachments to Section
L
To be completed only by a Mexico-domiciled or non-North America-domiciled motor carrier
ATTACHMENT A (for Section L, 44[c], Part III "Drug and Alcohol Testing," #2)
Below applicant has listed:
(1) The name, address and title of the person or persons designated by applicant as responsible for implementing and overseeing its
alcohol and drug testing programs.
(2) The name, address, and telephone number of both its drug testing laboratory and its alcohol testing service. If the alcohol testing
service information is identical to the information for the drug testing laboratory, applicant should enter “Same” in the space for the
alcohol testing service.
ADDRESS
NAME
TITLE
STREET
CITY
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STREET
CITY
STREET
CITY
TELEPHONE NUMBER
ADDRESS
NAME OF DRUG TESTING LABORATORY
STREET
CITY
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STREET
CITY
STREET
CITY
TELEPHONE NUMBER
ADDRESS
NAME OF ALCOHOL TESTING SERVICE
STREET
CITY
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STREET
CITY
STREET
CITY
FORM MCSA-1 [URS-1] Page 23 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
ATTACHMENT B (for Section L, 44[c], Part V "Accident Register," #2)
Applicant is attaching a copy of its accident register for the last 12 months.
Applicant is beginning operations and explains below how it will maintain its accident register once it begins operations in the U.S.:
ATTACHMENT C (for Section L, 44[c], Part V "Accident Monitoring Program," #4)
The following fully describes applicant's accident monitoring program for operations in the U.S.:
FORM MCSA-1 [URS-1] Page 24 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
ATTACHMENT D (for Section L, 44[c], Part VI "Production of Records," #2)
The following are employed by the applicant to respond to inquiries for records:
NAME
ADDRESS
TELEPHONE NUMBER
STREET
CITY
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STATE
ZIP CODE
STREET
CITY
STREET
CITY
STREET
CITY
STREET
CITY
ATTACHMENT E (for Section L, 44[c], Part VII "Hazardous Materials," #1)
Applicant is attaching a copy of the materials used to provide HM training. Below applicant has listed its employees (other than drivers)
who are responsible for ensuring compliance with HM regulations and a description of the HM safety functions of each employee.
Applicant has also attached a copy of its training materials.
NAME
DESCRIPTION OF HAZARDOUS MATERIAL SAFETY FUNCTION
FORM MCSA-1 [URS-1] Page 25 of 26
OMB No.: 2126-0051
Expiration: 11/30/2016
ATTACHMENT F (for Section L, 44[c], Part II "Hours-of-Service Monitoring Program," #3)
Applicant will describe below the monitoring procedures designed to ensure that its drivers complete log books correctly, as well as the
procedures for record keeping and review of drivers. If applicant has drivers operating under the 100 air-mile exception, describe the
maintenance of those records below as well. If necessary, attach supporting files to this document.
Attachments to Section
O
To be completed by both the Transferor and Transferee when Operating Authority Registration is transferred.
ATTACHMENT G (for Section O, "Notification of Transfers of Operating Authority Registration")
Applicant is attaching a copy of the operating authority registration that is being transferred.
FORM MCSA-1 [URS-1] Page 26 of 26
| File Type | application/pdf |
| File Title | FORM MCSA-1 |
| Subject | FMCSA Registration/Update(s).(Application for USDOT Number/Operating Authority Registration) |
| File Modified | 2014-01-03 |
| File Created | 2013-06-03 |