Please provide correct responses to each of the questions below. Incomplete application will not be processed and will delay the response time in receiving your numbers. Thanks for using our service.

To pay with your credit card, please provide your credit card infromation below. Your credit card will be charged $599. To pay with check or money order, please print and mail the form below with your check or money order for $599 to: Williams' Technology,
P O Box 1247, Livingston, AL 35470. 





 
		CREDIT CARD INFORMATION
 
		NAME ON CARD:             
 
		BILLING ZIP CODE:       
 
		CREDIT CARD TYPE:       
 
		CARD NO:                
 
		EXPIRES:                
 
		
 
		INFORMATION FOR APPLICATIONS
 
		NAME OF APPLICANT:      
 
		NAME OF OWNER:          
 
		SOCIAL SECURITY NO:     
 
		BUSINESS NAME:          
 
		EMAIL ADDRESS:          
 
		PHONE NO:               
 
		MOBILE NO:              
 
		MAILING ADDRESS:        
 
		CITY:                   
 
		STATE:                  
 
		ZIP CODE:               
 
		PHYSICAL ADDRESS:       
 
		CITY:                   
 
		STATE:                  
 
		COUNTY:                 
 
		ZIP CODE:

TYPE OF ENTITY SOLE PROPRIETARY PARTNERSHIP IF PARTNERSHIP, IDENTIFY PARTNERS:
DATE BUSINESS BEGAN: CLOSING MONTH OF ACCOUNTING YEAR:
HAVE YOU EVER APPLIED FOR EMPLOYER ID YES NO IF YES, GIVE LEGAL NAME OF BUSINESS:
TYPE OF OPERATION INTRASTATE INTERSTATE MILEAGE FOR LAST CALENDAR YEAR:


WHAT WILL YOU HAUL. PLEASE CHECK ALL THE APPLY.
GENERAL FREIGHT METAL PRODUCT MOTOR VEHICLE LUMBER BUILDING MATERIAL MACHINERY FARM SUPPLIES CONSTRUCTION

NUMBER OF TRACTORS: NUMBER OF TRAILERS: # OF CDL DRIVERS:

MAKE MODEL YEAR OF VEHICLE VIN #:
MAKE MODEL YEAR OF VEHICLE VIN #:
MAKE MODEL YEAR OF VEHICLE VIN #:
MAKE MODEL YEAR OF VEHICLE VIN #:

CERTIFICATION STATEMENT
I CERTIFY THAT I AM FAMILIAR WITH THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS AND/OR THE FEDERAL HAZARDOUS MATERIALS REGULATIONS. UNDER PENALTIES OF PERJURY, I DECLARE THAT THE INFORMATION ENTERED ON THIS REPORT IS, TO THE BEST OF MY KNOWLEDGE AND BELIEF, TRUE, CORRECT, AND COMPLETE.

HAVE YOU READ READ AND AGREE WITH THE CERTIFICATION STATEMENT ABOVE? YES NO
DO YOU NOW HAVE AUTHORITY FROM OR AN APPLICATION BEING PROCESSED BY THE FORMER ICC OR FMCSA? YES NO IF YES, IDENTIFY THE LEAD DOCKET NUMBER(S):

INSURANCE INFORMATION
THIS SECTION MUST BE COMPLETED BY ALL MOTOR PROPERTY CARRIER APPLICANTS. THE DOLLAR AMOUNTS IN PARENTHESES REPRESENT THE MINIMUM AMOUNT OF BODILY INJURY AND PROPERTY DAMAGE (LIABILITY) INSURANCE COVERAGE YOU MUST MAINTAIN AND HAVE ON FILE WITH THE FMCSA.
NOTE: REFER TO THE INSTRUCTIONS FOR INFORMATION ON CARGO INSURANCE FILING REQUIREMENTS FOR MOTOR COMMON CARRIERS AND SURETY BOND/TRUST FUND AGREEMENT FILINGS FOR PROPERTY BROKERS.

WILL YOU OPERATE VEHICLES HAVING GROSS VEHICLE WEIGHT RATINGS (GVWR) OF 10,000 POUNDS OR MORE TO TRANSPORT: YES NO IF YES, PLEASE READ BELOW FOR INSURANCE MINIMUM.
_ NON-HAZARDOUS COMMODITIES ($750,000).
_ HAZARDOUS MATERIALS REFERENCED IN THE FMCSA'S INSURANCE REGULATIONS AT 49 CFR 1043.2(B)(2)(C) ($1,000,000).

_ HAZARDOUS MATERIALS REFERENCED IN THE FMCSA'S INSURANCE REGULATIONS AT 49 CFR 1043.2(B)(2)(B) ($5,000,000).

WILL YOU OPERATE ONLY VEHICLES HAVING GROSS VEHICLE WEIGHT RATINGS (GVWR) UNDER 10,000 POUNDS TO TRANSPORT: YES NO IF YES, PLEASE READ BELOW FOR INSURANCE MINIMUM.
_ ANY QUANTITY OF CLASS A OR B EXPLOSIVES, ANY QUANTITY OF POISON GAS (POISON A), OR HIGHWAY ROUTE CONTROLLED QUANTITY OF RADIOACTIVE MATERIALS ($5,000,000).
_ COMMODITIES OTHER THAN THOSE LISTED ABOVE ($300,000).

SAFETY CERTIFICATION
APPLICANTS SUBJECT TO FEDERAL MOTOR CARRIER SAFETY REGULATIONS - IF YOU WILL OPERATE VEHICLES OF MORE THAN 10,000 POUNDS GVWR AND ARE, THUS, SUBJECT TO PERTINENT PORTIONS OF THE U.S. DOT'S FEDERAL MOTOR CARRIER SAFETY REGULATIONS AT 49 CFR, CHAPTER 3, SUBCHAPTER B (PARTS 350-399), YOU MUST CERTIFY AS FOLLOWS:
APPLICANT HAS ACCESS TO AND IS FAMILIAR WITH ALL APPLICABLE U.S. DOT REGULATIONS RELATING TO THE SAFE OPERATION OF COMMERCIAL VEHICLES AND THE SAFE TRANSPORTATION OF HAZARDOUS MATERIALS AND IT WILL COMPLY WITH THESE REGULATIONS. IN SO CERTIFYING, APPLICANT IS VERIFYING THAT, AT A MINIMUM, IT:
(1) HAS IN PLACE A SYSTEM AND AN INDIVIDUAL RESPONSIBLE FOR ENSURING OVERALL COMPLIANCE WITH FEDERAL MOTOR CARRIER SAFETY REGULATIONS;
(2) CAN PRODUCE A COPY OF THE FEDERAL MOTOR CARRIER SAFETY REGULATIONS AND THE HAZARDOUS MATERIALS TRANSPORTATION REGULATIONS;
(3) HAS IN PLACE A DRIVER SAFETY TRAINING/ORIENTATION PROGRAM;
(4) HAS PREPARED AND MAINTAINS AN ACCIDENT REGISTER (49 CFR 390.15);
(5) IS FAMILIAR WITH DOT REGULATIONS GOVERNING DRIVER QUALIFICATIONS AND HAS IN PLACE A SYSTEM FOR OVERSEEING DRIVER QUALIFICATION REQUIREMENTS (49 CFR PART 391);
(6) HAS IN PLACE POLICIES AND PROCEDURES CONSISTENT WITH DOT REGULATIONS GOVERNING DRIVING AND OPERATIONAL SAFETY OF MOTOR VEHICLES, INCLUDING DRIVERS' HOURS OF SERVICE AND VEHICLE INSPECTION, REPAIR, AND MAINTENANCE (49 CFR PARTS 392, 395 AND 396);
(7) IS FAMILIAR WITH AND WILL HAVE IN PLACE ON THE APPROPRIATE EFFECTIVE DATE, A SYSTEM FOR COMPLYING WITH U.S. DOT REGULATIONS GOVERNING ALCOHOL AND CONTROLLED SUBSTANCES TESTING REQUIREMENTS (49 CFR 382 AND 49 CFR PART 40).

EXEMPT APPLICANTS - IF YOU WILL OPERATE ONLY SMALL VEHICLES (GVWR UNDER 10,000 POUNDS) AND WILL NOT TRANSPORT HAZARDOUS MATERIALS, YOU ARE EXEMPT FROM FEDERAL MOTOR CARRIER SAFETY REGULATIONS, AND MUST CERTIFY AS FOLLOWS:
APPLICANT IS FAMILIAR WITH AND WILL OBSERVE GENERAL OPERATIONAL SAFETY GUIDELINES, AS WELL AS ANY APPLICABLE STATE AND LOCAL LAWS AND REQUIREMENTS RELATING TO THE SAFE OPERATION OF COMMERCIAL MOTOR VEHICLES AND THE SAFE TRANSPORTATION OF HAZARDOUS MATERIALS.

HAVE YOU READ AND AGREE TO COMPLY WITH THE GUIDELINES ABOVE? YES NO

AFFILIATION WITH OTHER FORMER ICC, NOW FMCSA-LICENSED ENTITIES. DISCLOSE ANY RELATIONSHIP YOU HAVE OR HAVE HAD WITH ANY OTHER FMCSA-REGULATED ENTITY WITHIN THE PAST 3 YEARS. FOR EXAMPLE, THIS COULD BE THROUGH A PERCENTAGE OF STOCK OWNERSHIP, A LOAN, OR A MANAGEMENT POSITION. IF THIS REQUIREMENT APPLIES TO YOU, PROVIDE THE NAME OF THE COMPANY, MC-NUMBER, DOT NUMBER, AND THAT COMPANY'S
LATEST U.S. DOT SAFETY RATING:


APPLICANT'S OATH
THIS OATH APPLIES TO ALL SUPPLEMENTAL FILINGS TO THIS APPLICATION. THE SIGNATURE MUST BE THAT OF THE APPLICANT, NOT LEGAL REPRESENTATIVE.

I, VERIFY UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE UNITED STATES OF AMERICA, THAT ALL INFORMATION SUPPLIED ON THIS FORM OR RELATING
TO THIS APPLICATION IS TRUE AND CORRECT. FURTHER, I CERTIFY THAT I AM QUALIFIED AND AUTHORIZED TO FILE THIS APPLICATION. I KNOW THAT WILLFUL MISSTATEMENTS OR OMISSIONS OF MATERIAL FACTS CONSTITUTE FEDERAL CRIMINAL VIOLATIONS PUNISHABLE UNDER 18 U.S.C. 1001 BY IMPRISONMENT UP TO 5 YEARS AND FINES UP TO $10,000 FOR EACH OFFENSE. ADDITIONALLY, THESE MISSTATEMENTS ARE PUNISHABLE AS PERJURY UNDER 18 U.S.C. 1621, WHICH PROVIDES FOR FINES UP TO $2,000 OR IMPRISONMENT UP TO 5 YEARS FOR EACH OFFENSE.

I FURTHER CERTIFY UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE UNITED STATES, THAT I HAVE NOT BEEN CONVICTED, AFTER SEPTEMBER 1, 1989, OF ANY FEDERAL OR STATE OFFENSE INVOLVING THE DISTRIBUTION OR POSSESSION OF A CONTROLLED SUBSTANCE, OR THAT IF I HAVE BEEN SO CONVICTED, I AM NOT INELIGIBLE TO RECEIVE FEDERAL BENEFITS, EITHER BY COURT ORDER OR OPERATION OF LAW, PURSUANT TO SECTION 5301 OF THE ANTI-DRUG ABUSE ACT OF 1988 (21U.S.C. 862)

FINALLY, I CERTIFY THAT APPLICANT IS NOT DOMICILED IN MEXICO OR OWNED OR CONTROLLED BY PERSONS OF THAT COUNTRY.

IF YOU ARE THE APPLICANT AND HAS READ AND AGREE WITH THE ABOVE OATH, PLEASE PROVIDE YOUR FULL LEGAL NAME HERE:

DATE OF APPLICATION:


ICC Authority, DOT Number, Tax ID Number, Single State Registration, BOC-3, Heavy Highway Use ALL ONLY $599