1.  Motor Carrier For- Hire Hauling Exempt Loads

1. Motor Carrier For- Hire Hauling Exempt Loads

If you are hauling exempt loads such as grain, livestock or logs in-state or crossing state lines, enter 'Yes'

2.  The State (or the main State) your Business is located in

2. The State (or the main State) your Business is located in

Please spell out the entire name of your state and not abbreviate the state name

3.  Maximum Extent of Operations:  Interstate

3. Maximum Extent of Operations: Interstate

If you are going to cross state lines, enter 'Yes' - If you are not going to cross state lines and remain in-state, leave the box blank

4.  Intrastate Only

4. Intrastate Only

If you are not going to cross state lines and will remain in the state with your truck or trucks, enter 'Yes' - otherwise leave the box blank

5.  All trucks with a Gross Vehicle Weight Rating of less than 10,000-lbs

5. All trucks with a Gross Vehicle Weight Rating of less than 10,000-lbs

If your truck does not have, or if none of your trucks have a Gross Vehicle Weight Rating (GVWR) of 10,000-lbs or more stamped on the door jamb, or if your truck and trailer do not have Combined Gross Vehicle Weight Ratings of 10,000-lbs or more, enter 'Yes' - otherwise leave the box blank

6.  One or more trucks have a GVWR of 10,000-lbs or more

6. One or more trucks have a GVWR of 10,000-lbs or more

If your truck, or if one of your trucks has a Gross Vehicle Weight Rating (GVWR) of 10,000-lbs or more, OR, if you will be pulling a trailer where the COMBINED Gross Vehicle Weight Ratings of both the truck and the trailer are 10,000-lbs or more, enter 'Yes' - otherwise leave the box blank

7.  Name of the Company Official, or Owner

7. Name of the Company Official, or Owner

Please enter First Name, Middle Initial and Last Name

8.  Title of Company Official, or Owner

8. Title of Company Official, or Owner

Enter 'President' if the company is a Corporation; 'Member' if the company is an LLC; 'Owner' if yuo are the owner

9.  Legal Name

9. Legal Name

Enter your personal name if you are the 'Owner'. If the company is a Corporation or an LLC, enter the entire name of the Corporation or LLC followed by 'Inc.' or 'LLC'

10.  'Doing Business As' or d/b/a name

10. 'Doing Business As' or d/b/a name

If the legal name is your personal name and you are not using a Corporate or LLC name, you can use a 'Doing Business As' name, or d/b/a name. If you want to use a d/b/a name, the d/b/a name will follow your personal name such as John Smith d/b/a Smith Transport, or John Smith d/b/a JS Transport. If you want to use a d/b/a name, do not enter your personal name, enter only the d/b/a name you would like to use for your business

11.  Physical Address - Street

11. Physical Address - Street

In addition to your physical address, if you have a separate mailing address, you can enter the mailing address in box # 19 below. We still need your physical address to be entered here. Enter your street address in the box below

12.  City

12. City


13.  County

13. County


14.  State

14. State

Please spell out the entire name of you r state. Please do not abbreviate the state name

15.  Zip Code

15. Zip Code


16.  Phone Number

16. Phone Number


17.  Cell Phone #

17. Cell Phone #


18.  Fax Number

18. Fax Number


19.  Mailing Address - P.O. Box, or Different Street Address

19. Mailing Address - P.O. Box, or Different Street Address

P.O. Box or different street address to receive mail

20.  City

20. City


21.  State

21. State


22.  Zip Code

22. Zip Code


23.  EIN Federal ID Number

23. EIN Federal ID Number

If you have a Federal ID Number and know this number, please enter the number in the box below. If you are a Corporation or an LLC, we will need this number. The number is a two digit number followed by a dash and seven digits (12-3456789). If you are a Corporation or an LLC and you do not have a Federal ID Number, call us and we can apply for a number. If your truck, or tractor and trailer combination is over 54,000-lbs, you will need an EIN for your 2290 Highway Use Tax.

24.  Social Security Number

24. Social Security Number

Not needed if your company is a Corporation or an LLC

25.  E-Mail Address

25. E-Mail Address


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Greatlakes@gls.comcastbiz.net

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