[Code of Federal Regulations] [Title 49, Volume 4] [Revised as of October 1, 2004] From the U.S. Government Printing Office via GPO Access [CITE: 49CFR367.7] [Page 840-841] TITLE 49--TRANSPORTATION DEPARTMENT OF TRANSPORTATION PART 367_STANDARDS FOR REGISTRATION WITH STATES--Table of Contents Sec. 367.7 Violations unlawful; criminal penalties and civil sanctions. Any violation of the provisions of these standards is unlawful. Nothing in these standards shall be construed to prevent a State from imposing criminal penalties or civil sanctions upon any person or organization violating any provision of them. Appendix A to Part 367--Uniform Application for Single State Registration for Motor Carriers Registered with the Secretary of Transportation Motor Carrier Identification Numbers: FMCSA MC No.(s.)________________________________________________________ US DOT No.______________________________________________________________ Applicant (Identical to name on FMCSA order): Name:___________________________________________________________________ D/B/A___________________________________________________________________ Principal Place of Business Address: \1\ --------------------------------------------------------------------------- \1\ A principal place of business is a single location that serves as a motor carrier's headquarters and where it maintains or can make available its operational records. --------------------------------------------------------------------------- Street__________________________________________________________________ City____________________________________________________________________ State___________________________________________________________________ Zip_____________________________________________________________________ Mailing Address if Different From Business Address Above: Street__________________________________________________________________ City____________________________________________________________________ State___________________________________________________________________ Zip_____________________________________________________________________ Type of Registration: [ ] New Carrier Registration-- The motor carrier has not previously registered. [ ] Annual Registration-- The motor carrier is renewing its annual registration. [ ] Supplemental Registration-- The motor carrier is adding additional vehicles or States of travel after its annual registration. [ ] New Registration State Selection-- The motor carrier has changed its principal place of business or its prior registration State has left the registration program. The prior registration State was --------------------. [ ] Additional States not registered in prior years. List ________________________________________________________________________ ________________________________________________________________________ Type of Motor Carrier: (Check one) [ ] Individual [ ] Partnership [ ] Corporation If corporation, give State in which incorporated:------------------ -- List names of partners or officers: Name:___________________________________________________________________ Title:__________________________________________________________________ Name:___________________________________________________________________ Title:__________________________________________________________________ Name:___________________________________________________________________ Title:__________________________________________________________________ Type of FMCSA Registered Authority: Permanent Certificate or Permit [ ] Temporary Authority (TA) [ ] Emergency Temporary Authority (ETA) [ ] FMCSA Certificate(s) or Permit(s): [ ] FMCSA Authority Order(s) attached for initial registration. [ ] FMCSA Authority Order(s) attached for additional grants received. [ ] No change from prior year registration. Proof of Public Liability Security: [ ] The applicant is filing, or causing to be filed, a copy of its proof of public liability security submitted to and accepted by the FMCSA under 49 CFR part 387, subpart C. [ ] The applicant has filed, or caused to be filed, a copy of its proof of public liability security submitted to and accepted by the FMCSA under 49 CFR part 387, subpart C, and the security remains in effect. FMCSA Approved Self-Insurance or Other Securities: [ ] FMCSA Insurance order attached for new carrier registration. (Check one when completing for annual registration.) [ ] The FMCSA Order approving the self-insurance plan or other security is still in full force and effect, and the carrier is in full compliance with all conditions imposed by the FMCSA Order. [ ] The motor carrier is no longer approved under a self-insurance plan or other security, and the motor carrier will file, or [[Page 841]] cause to be filed, a copy of proof of public liability security with this application in the registration State. Hazardous Materials: (Check one) [ ] The applicant will not haul hazardous materials in any quantity. [ ] The applicant will haul hazardous materials that require the following limits in accordance with Title 49 CFR 387.303: (Check one) [ ] Public Liability and Property Damage Insurance of $1 million. [ ] Public Liability and Property Damage Insurance of $5 million. Process Agents: [ ] FMCSA Form No. BOC-3 or blanket designation attached for new registration. [ ] FMCSA Form No. BOC-3 or blanket designation attached reflecting changes of designation of process agents. [ ] No change from prior year registration. Certification: I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration State.) Name (Printed)__________________________________________________________ Signature_______________________________________________________________ Title___________________________________________________________________ Telephone Number________________________________________________________ Date____________________________________________________________________ [58 FR 28933, May 18, 1993. Redesignated at 61 FR 54707, Oct. 21, 1996, as amended at 62 FR 15420, Apr. 1, 1997]