Taylor Made Truckers Service, Inc.
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(704) 299-3958 OFFICE
(704) 969-2562 FAX
www.taylormadetruckers.com
PO Box 620934
Charlotte, NC 28262
301 McCullough Drive Suite 415
Charlotte, NC 28262
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FEDERAL HIGHWAY ADMINISTRATION OPERATING AUTHORITY APPLICATION
DATE: ______
1. CARRIER'S LEGAL NAME: ______
2. TRADE NAME (DBA IF ANY): ______
3. PHYSICAL ADDRESS: ______
CITY: ______STATE:______ZIP CODE: ______
COUNTY BUSINESS IS LOCATED IN:______
MAILING ADDRESS: ______
CITY: ______STATE:______ZIP CODE: ______
4. TELEPHONE#: ______FAX#: ______
CELL #: ______
5. FEDERAL ID#: ______OR SS#: ______
6. CONTACT PERSON: ______TITLE: ______
NOTE: A CORPORATE OFFICER MUST SIGN THE APPLICATION WHEN
THE APPLICANT IS A CORPORATION
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7. TYPE OF AUTHORITY TO BE APPLIED FOR:
( ) CONTRACT CARRIER ( ) COMMON CARRIER ( ) PROPERTY BROKER
NOTE: EACH ADDITIONAL AUTHORITY REQUESTED WILL REQUIRE
AN ADDITIONAL $300.00 FEE.
8. TYPE OF BUSINESS:
( ) CORPORATION
STATE OF INCORPORATION: ______DATE: ______
PRESIDENT NAME: ______SSN#: ______
DATE OF BIRTH: ______
SECRETARY NAME: ______SSN#: ______
DATE OF BIRTH: ______
( ) LIMITED LIABILITY CORPORATION (LLC)
MEMBER MANAGERS NAME: ______SSN#: ______
DATE OF BIRTH: ______
( ) SOLE PROPRIETORSHIP
INDIVIDUALS NAME: ______SSN#: ______
( ) PARTNERSHIP
1ST PARTNERS NAME: ______SSN#: ______
DATE OF BIRTH: ______
2ND PARTNERS NAME: ______SSN#: ______
DATE OF BIRTH: ______
3RD PARTNERS NAME: ______SSN#: ______
DATE OF BIRTH: ______
9. MC NUMBER OF CURRENT ICC OR FHWA AUTHORITY: ______
ALSO PLEASE ATTACH COPIES OF AUTHORITIES
10. DO YOU CURRENTLY HOLD A US DEPARTMENT OF TRANSPORTATION
(US DOT) CARRIER NUMBER? ( ) YES ( ) NO
IF SO, WHAT IS YOUR NUMBER US DOT NUMBER: ______
11. HAVE YOU RECEIVED A US DOT SAFETY RATING?
( ) NO
( ) YES
IF SO, PLEASE ATTACH A COPY OF THE RATING.
12. PLEASE CHECK ALL THAT APPLY OF THE COMMODITIES LISTED BELOW
THAT YOUR COMPANY WILL TRANSPORT:
( ) GENERAL COMMODITIES INCLUDING BULK
FOR GENERAL COMODITY AUTHORITY INCLUDING BULK YOUR
FIRM MUST HAVE $750,000 IN PUBLIC LIABILITY INSURANCE AND
$10,000 IN CARGO.
( ) HAZARDOUS MATERIALS IN BULK OR THAT ARE CLASSIFIED IN AN
EXTREMELY VOLITAL CATEGORY
FOR THIS EXTREMELY VOLATILE AND/OR HAZARDOUS MATERIAL
IN BULK AUTHORITY YOUR COMPANY MUST HAVE 5 MILLION IN
PUBLIC LIABILITY INSURANCE AND $10,000 IN CARGO.
( ) HOUSEHOLD GOODS CARRIER
( ) PASSENGER AUTHORITY
13. LIABILITY INSURANCE:
AGENT’S NAME: ______
PHONE NUMBER: ______
FAX NUMBER: ______
IMPORTANT NOTE: PLEASE ALLOW 14 TO 21 WORKING DAYS TO RECEIVE YOUR PERMANENT AUTHORITY.
PLEASE RETURN COMPLETED APPLICATION AND FILING FEE TO:
TAYLOR MADE TRUCKERS SERVICE, INC.
PO BOX 620934
CHARLOTTE, NC 28262
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