Legal Company Name

DBA (if applicable)

Years in Business

MC Number

USDOT Number

EIN or SSN (Optional)

Primary Contact Name

Phone Number

Email Address

Dispatch Email (if different)

Physical Address

City

State

Zip Code

Auto Liability Amount

Cargo Insurance Amount

Insurance Company Name

Insurance Agent Name

Agent Phone

Agent Email

Equipment Type
Dry VanReeferFlatbedStep DeckPower OnlyOther

Number of Trucks

W-9 (PDF)

Certificate of Insurance (COI)

Authority Letter (MC Certificate)

I agree to comply with all federal and state transportation regulations

I certify all information provided is accurate