Free MV2843 Wisconsin Motor Carrier Authority Application - Wisconsin

WISCONSIN MOTOR CARRIER AUTHORITY APPLICATION
Wisconsin Department of Transportation MV2843 6/2007 Ch. 194 Wis. Stats.

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Instructions and insurance requirements are on the reverse side.
Please do not submit this application until a Form E ­ Uniform Motor Carrier Bodily Injury and Property Damage Liability Certificate of Insurance is on file with the State of Wisconsin or Form BMC91X is on file with the Federal Motor Carrier Safety Administration.
US DOT# ­ Mandatory Federal Employer Identification Number (FEIN) ­ Mandatory Business Type Existing Fuel Tax

Yes
IFTA Number

No

Individual ­ Birth Date: Partnership Corporation/LLC ­ Incorporation Date: Note: Wisconsin corporations/LLCs must be on file with the Department of Financial Institutions. Exempt out-of-state carriers may send a copy of their Articles of Incorporation.

Yes

No Did you ever have IRP plates under another name? If yes, provide name and account number.
IRP Account Number

Company Name

Legal Applicant Name (Insurance certificate and vehicle registration must be filed in this name.)

Name and Address of each partner if partnership, officer and director if a corporation, each member if an LLC (Or attach a copy of the Articles of Inc)

Principal Place of Business / Physical Address

Mailing Address

List all types of commodities that you usually transport

Type of For Hire Authority Requested Wisconsin Intrastate Property Fee (LC ­ hauling within Wisconsin) = $500.00 Note: Out-of-state corporations operating intrastate in Wisconsin are required to file with the Department of Financial Institutions as a foreign corporation. Contact them at 608-261-7577. Interstate Exempt (ICX - hauling exempt commodities between states) = $25.00 Wisconsin Intrastate Passenger Fee (PC - hauling passengers on a fixed route within Wisconsin) = $50.00 AMENDED APPLICATION (Name change = no fee.) See instructions on reverse side.
(Note: Make sure to contact other agencies with this name change, i.e., IRP, USDOT, IFTA, FMCSA AND IRS. Do not submit this application until the names are updated with FMCSA - SAFER)
Former Name USDOT# LC# MC#

I certify, with penalty of perjury that the information furnished on this application and the attached schedules, if applicable, is true and correct, and that I have knowledge of the applicable Federal and State safety regulations and that the applicant has financial ability to provide cargo insurance or has adequate financial resources to pay damage claims.
(Area Code ­ Telephone Number) (Area Code ­ FAX Number) (Signature) (Date)

(E-mail Address) Your authority will be sent to your e-mail address.

(Name ­ Print)

WisDOT USE ONLY
Wisconsin Account Number Date Issued Fee(s) Authority Number(s) Issued

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WISCONSIN MOTOR CARRIER AUTHORITY APPLICATION INSTRUCTIONS USDOT NUMBER Authorities cannot be issued without a USDOT number. Call 1-800-832-5660 or apply online via www.safersys.org. You may obtain a paper copy of the Federal application form MCS150 and mail it to the US Department of Transportation. Your USDOT number must appear on the FMCSA "SAFER" system. A motor carrier is required to display their USDOT on vehicles meeting the definition of a CMV (10,001 lbs. GVW and over) as found in Part 390.5 INSURANCE Arrange for liability insurance as required by s.194.41, Wisconsin Statutes. Have your insurance agent contact the Commercial Underwriter and request that the insurance company file proof of insurance coverage electronically. Although we accept mailed or FAXed copies of FORM E, filings done electronically will expedite the application process. Insurance companies can contact this office for information regarding electronic filing. Interstate regulated carriers are required to file a BMC91X Federal Liability Certificate. The commercial underwriter will file this with the FMCSA electronically. WisDOT will use the information from the federal website to verify insurance coverage. NAME CHANGES If you add or delete a partner, incorporate, or have any type of legal name change, you must check the box indicating that this is an amended application. If you have had a corporate name change and are not from Wisconsin, you must file with the Department of Financial Institutions (DFI) as a foreign corporation or provide a copy of the amended articles of incorporation. If you are a Wisconsin resident, you must contact DFI to file the corporate name change at 608-261-7577. Interstate regulated carriers are required to contact the FMCSA to make the name change. WisDOT will use the information from the federal website to verify the corporate name change. Note: Two or more corporations that merge and form a new corporation under a new name is not considered a corporate name change. TRANSFER OF AUTHORITY Authority issued by the State of Wisconsin is not considered to be part of the sale of a business unless it is specifically identified as an asset of the company. If you are leaving a partnership, and the other partners wish to continue operating with that authority, you must sign the statement below. I relinquish the right to authority number(s)
LC# ICX# USDOT# MC#

(Signature of Person Leaving Partnership)

(Date)

(Name ­ Print)

REMITTANCE - Make your check or money order payable to: Registration Fee Trust SUBMITTAL ­ Mail the application to the following address: Wisconsin Department of Transportation Motor Carrier Insurance Unit PO Box 7967 Madison, WI 53707-7967 If you have any questions, please contact us at 608-266-1356.
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