We can help you obtain the authority that is proper for you.  Complete the following form and press submit. After review of this form we will call you and verify all information to ensure your filing is accurate.   

If you need any assistance with this page please call 

United Fuel Tax Services at 1-877-870-5764. Toll Free

I AM APPLYING FOR THE FOLLOWING AUTHORITY(S) FREIGHT or PASSENGER 

Common Contract Broker (except Household Goods) Broker (of Household Goods) Freight Forwarder

I WILL BE TRANSPORTING THE FOLLOWING COMMODITIES: (Freight carriers only)

General commodities, non-hazardous commodities (Minimum of $750,000 BI&PD required)

Household goods (Minimum of $750,000 BI&PD required)

Hazardous materials that require a minimum of $1,000,000 BI&PD

Hazardous materials that require a minimum of $5,000,000 BI&PD

NOTE: Carriers must have a minimum of $10,000 cargo insurance.

Will operate vehicles having Gross Vehicle Weight Ratings (GVWR) of 10,000 pounds or more.

Will operate vehicles having GVWR under 10,000 pounds.

APPLICANT:

DOING BUSINESS AS:

SSN or EIN:

PHYSICAL ADDRESS, CITY, STATE & ZIP CODE:

MAILING ADDRESS, CITY, STATE & ZIP CODE:

TELEPHONE NUMBER: FAX NUMBER : Email:

BUSINESS FORM: Individual; Partnership; Corporation (State - ); LLC (State -

ACTUAL COMMODITIES TO BE TRANSPORTED:

YOU MUST ANSWER "YES" OR "NO" TO THE FOLLOWING QUESTIONS:

1. (Yes) or (No) Do you have ICC/FHWA Authority now? MC#

2. (Yes) or (No) Do you or anyone connected with company now have interest in any other ICC/FHWA regulated carrier or broker? If "YES" list Name of Company and MC#

3. (Yes) or (No) Have you ever had a DOT Safety Audit? PRESENT DOT NUMBER (IF ANY) Safety Rating (If any)

4. (Yes) or (No) Have you been convicted after September 1, 1989, of distribution or possession of a controlled substance?

5. (Yes) or (No) Will your operations be conducted in compliance with the DOT rules and regulations or safety?

6. (Yes) or (No) Are you domiciled, owned, or controlled by persons in Mexico?

YES, Please send me a FREE State Permit Quote!

# of Vehicles: Gross Vehicle Weight:   

Single State Registration: All States or;  Selected participating states...AL, AR, CA, CO, CT, GA, ID, IL, IN, IA, KS, KY, LA, ME, MA, MI, MN, MS, MO, MT, NE, NH, NM, NY, NC, ND, OH, OK, RI, SC, SD, TN, TX, UT, VA, WA, WV, and WI.

SSRS NOTE: AZ, DE, FL, NJ, MD, NV, OR, PA, VT and WY are not participants in the Single State Registration Program and therefore this credential is not required to travel in these states.  If you are based in a non-participating state we will file your application in a neighboring state to fulfill this requirement. 

IFTA/Mileage Tax Permits:  IFTA  Base State: ; KY; NM; NY; OR (Bond Required)

Applicants Name:

Referred By:

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