LB Safety Operations Services, Inc.
931-657-5667
Fax 931-657-5668
Unified Carrier Registration Form
Section 1. General Information: The owner and DBA name should be identical to what is on file for you USDOT number (See http://safer.fmcsa.dot.gov/CompanySnapshot.aspx ).
USDOT Number MC Number
Telephone Number Fax Number
Legal Name
DBA
Principle Place of Business
City State Zip
Mailing Address
City State Zip
Section 2. Classification:
Motor Carrier Motor Private Carrier Broker Leasing Company Freight Forwarder
Broker, Freight Forwarders, and Leasing Company (not a motor carrier combination) go to Section 4.
Section 3. No. of Motor Vehicles - Motor Carrier & Motor Private Carrier
Check only one box:
The number of vehicles shown below have been taken from section 26 of your last reported MCS-150 form.
The number of vehicles shown below is the total number owned and operated for the 12 month period end June 30.
Number of Straight Trucks And/Or Tractors Number of Trailers
Number of Motor coaches, School Buses, Mini Buses, Limosines & Vans
Are any of the Straight Trucks, Tractors or Trailers (not passenger vehicles) used in INTRASTATE ONLY? (within state lines)
Number of above noted units used EXCLUSIVELY for intrastate commerce
Section 4. Certification
Full legal name of the person completing this application:
Position (owner, partner, president, etc)
I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute this document and authorize LB Safety Operations Services, Inc. to file my UCR electronically on my behalf.
Signature
Date
Payment Method: Will Call with CC Info. Please call for CC Info.
I would like a free quote for receiving up to 95% advances within 24hours on your freight invoices with no contract terms, no application fees, no startup fees, unlimited credit checks, On-line account access, and more?: Yes No
Please Print, And FAX to 931-657-5668