Applicant Information 

I AM REQUESTING TTA FILE FOR THE FOLLOWING ON MY BEHALF:

Freight Broker Authority (Broker of Property except Household Goods) Freight Broker Authority of Household Goods

Do you now have authority from or an application being processed by the former ICC or FMCSA? 

If Yes, identify the lead docket number(s) MC-

Doing Business As

Federal Tax ID or Social  

Legal Business Name

Doing Business As

Business Address

PO Box/Street  

City State   Zip

Mailing Address

PO Box/Street

City State   Zip  

DOT Number
If pending, please leave blank.

Form of Business (Check only one and fill in the corresponding blank):

Corporation

State of Incorporation

Sole Proprietorship

Name of Individuals

Partnership

Identify Partners

Affiliation with other former ICC, FHWA or OMCS 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 management position. If this requirement applies to you, provide the name of the company, MC number, USDOT number, and that company's latest DOT safety rating.

Please enter no more than 370 characters in the above field.

This oath applies to all supplemental filings to this application.

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 (21 U.S.C. 862)

Finally, I certify that applicant is not domiciled in Mexico or owned or controlled by persons of that country.

(Note: This portion of Applicant's oath does not pertain to applications that are U.S. based enterprises owned or controlled by persons of Mexico seeking to provide truck services for the transportation of international cargo between points in the United States.)

Yes I HAVE READ AND UNDERSTAND THIS OATH AND REQUEST THAT TTA FILE USING ALL INFORMATION I HAVE GIVEN THEM ON MY BEHALF.

I AM ALSO INTERESTED IN HAVING TTA ASSIST ME WITH MEETING THE FOLLOWING REQUIREMENTS:

SURETY BOND/TRUST FUND

BOC-3

SCAC

Your Name: (required)

Your Daytime Phone number: (required)

Your Email Address: (required)

By typing an x in this box, I understand that this application WILL NOT be submitted to TTA until I have completed the application process by adding the appropriate filings to the shopping cart and completing the payment process with either a major credit card or PayPal account.