APPLICATION FOR MOTOR CARRIER PERMIT

The information required on this form pertains to eligibility for issuance of a Motor Carrier Permit (MCP) and is required under authority of Division 14.85 of the California Vehicle Code (CVC). Failure to provide the information required under CVC Section 34621 is cause for refusal to issue an MCP.

The information provided on this form is public record regularly used by law enforcement agencies and is open to inspection by the public except driver license number, Social Security Number, Federal Employer Identification Number, Employer Pull Notice requester code number, payment information, and employees’ information.

Please read the instructions before completing this application.

NOTE: The law allows the State Board of Equalization and Franchise Tax Board to share taxpayer information with the Department of Motor Vehicles (DMV). Motor carriers are required to pay their state tax obligation. If the state tax obligation is not paid, DMV may suspend an MCP pursuant to the Business and Professions Code Section 494.5.

Applicant Information

Carrier Identification Number (CA#)

Type of Application

A. Original

B. Reinstatement

C. Renewal

D. Seasonal Original/Renewal

E. Seasonal Extension

Do you need to make changes, other than address or vehicle information, to your renewal?

Yes

No

Type of Business Entity?

A. Individual

B. Corporation

C. Limited Liability Company

D. Partnership

Please check this box if this is a Limited Partnership

Last Name

First Name

Middle Initial

Name of Corporation

Name of Limited Liability Company As Registered with the Secretary of State

Name of Partnership

Applicant Email

Re-enter Applicant Email

Type of Business Entity

A. Individual

B. Corporation

C. Limited Liability Company

D. Partnership

Last Name Specify name as shown on your drivers license or identification card

First Name Specify name as shown on your drivers license or identification card

Middle Initial

Driver License No.

State Issued Value is not selected

Name of Corporation As Registered with the Secretary of State

Name of Limited Liability Company As Registered with the Secretary of State

Name of Partnership If LLC Partnership, the name must be as registered with the Secretary of State

Intrastate_USDOT - Formula

Interstate_USDOT - Formula

Applicant Email

Carrier Identification Number (CA) #

Entity Number

Name of Corporation Please confirm the name below is correct

Name of Limited Liability Company Please confirm the name below is correct

Name of Partnership Please confirm the name below is correct

Name of Partnership

Operating Authority

Intrastate - Operate in California only

Interstate

USDOT # (if applicable) Enter 7-digit USDOT number

USDOT Number Enter 7-digit USDOT number

Blank Operating Authority

Intrastate_USDOT - Formula

Interstate_USDOT - Formula

Employer Pull Notice (EPN) Program

Unknown

Applied

Pending

EPN Number

Blank EPN

Are you a Registration Service completing this form on behalf of the applicant?

Yes

No

Registration Service Occupational License Number

License Expiration Date

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. *

Certified Document

Hire Base Fees

Hire CIF

Hire Total

Private Base Fees

Private CIF

Private Total

UiPath Bot Response Code

MCP Renewal - Exception Reason

MCP Renewal - Final Transaction Status Successful, Business Exception or Application Exception

MCP Renewal - Steps Performed List of activities performed by the UiPath Bot

Status Code 1

Queue ID 1

Email Verification - Final Transaction Status Successful, Business Exception or Application Exception

Email Verification - Exception Reason

Status Code 2

Queue ID 2 MCP_Renewal Queue ID

Queue ID 3 QuickWeb Queue ID

Transaction Confirmation - Type Original or Reinstatement or Renewal or Seasonal Original/Renewal or Seasonal Extension

Transaction Confirmation - Name First Last or Corporation or LLC or Partnership

Background Submit Text Change

All Other Stages

Initiate Request Stage

Payment Verification Stage

Entity Number if element958 = length 6 then add leading 0 else element958

Name Corporation or LLC or Partnership

USDOT#

FEIN_Corp

FEIN_LLC

FEIN_Partnership

UCR Authority Mapping 2

Filled

Not filled

USDOT #

Filled

Not filled

MC#

Filled

Not filled

MX#

Filled

Not filled

IFTA

Filled

Not filled

IRP

Filled

Not filled

Date of PreRequest

Carrier ID 1

Carrier ID 2

CarrierIdentNum

Email

I. Any truck or any combination of a truck and/or any other vehicle transporting hazardous materials. (See SECTION 5, box D)

Checked

Not Checked

Operating Authority

Intrastate - Operate in California only

Interstate

USDOT#

Employer Pull Notice (EPN) Program

A. EPN # Required - You are a Corporation, LLC, or Partnership, and your motor carrier operation requires drivers to hold a Commercial Driver License or you employ drivers, use friends or family, or the vehicles are operated by members of your entity. You are an individual who has two or more vehicles and at least one of your vehicles requires the driver to hold a Commercial Driver License.

B. Owner Operator - You are an Individual who has one vehicle which requires a Commercial Class A, Commercial Class B, or Class C with a special certificate or endorsement and no more than three trailers. (Not applicable for Corporations, LLCs, or Partnerships).

C. EPN # NOT Required (Enter information below)

EPN Requester Code

Certify Mapped

Checked

Not Checked

EnrolledORExemptCAST

Enrolled

Exempt

Type of Business Entity?

A. Individual

B. Corporation

C. Limited Liability Company

D. Partnership

IndLName

IndFName

IndMI

Select Identification Option

Employer Identification No. / Taxpayer Identification No.

Social Security No.

ID number 1

ID number 2

ID number 3

ID number 4

ID Condition 1 & 2

ID Condition 3 & 4

Full ID

CorpName

LLC Name

PartnershipName

Tel 1

Tel 2

Tel 3

Telephone Number

BusinessAddressLine1

BusinessAddressLine2

BusinessAddressCity

BusinessAddressCounty

BusinessAddressState

zip1

zip2

BusinessAddressZippCode

IsMaillingAddressDifferent

MailingAddressIsInternational

MailingAddressLine1

MailingAddressLine2

MailingAddressCity

MailingAddressCounty

MailingAddressState

Zip1b

Zip2b

MailingAddressZippCode

MailingAddressCountry

Enrolled or Exempt from a CSAT

VehiclesForHire

VehcilesPrivate

VehiclesTotal

T1

T2

TotalEmployees

WorkersCompensation

No Change Base Fee -- numeric

No Change CIF Amount --- numeric

Total Fee due --- numeric

No Change Convert Base Fee

No Change Conver CIF

No Change Convert Total Fee

Change Convert Base Fee

Change Convert CIF

Change Convert Total

BaseFeeAmount

CIFAmount

TotalFeeDue Rounded

PreparerPrintedName

PreparerPrintedEmail

RegistrationSeviceName

RegistrationAddress1

RegistrationAddress2

RegistrationCity

RegistrationState

Zip no change

Zip change

RegistrationZipp

RegistrationPhone

OccupationalLicenseNum

Date no Change

Date CHange

LicenseExpirationDate

Date no change

Date CHange

RegistrationServiceDate

ApplicantPrintedName

ApplicantPrintedEmail

ApplicantTitle

CustomerName

SignedAtCity

No Change Date

Change Date

CertDate

IMPORTANT: After verifying your information, an email notification will be sent to your email address with a link to continue your application. The link will expire after 72 hours.

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DMV - Motor Carrier Permit Application 2.0

Applicant Information