Company Information

Company Name *

DBA (if different):

Street Address: *

Country: *

Enter Country

State: *

City: *

Postal code: *

Phone *

Website *

Federal Tax ID / EIN: *

Business Structure *

Sole proprietor

Corporation

LLC

Partnership

Other

DOT registration

USDOT No. *

MC/ Docket No. *

DOT Operation Type *

Interstate

Intrastate

Both

DOT mode (check all that apply): *

FMCSA — motor carrier

FTA — transit

USCG — maritime

FRA — rail

PHMSA — pipeline

FAA — aviation

Non-DOT only

Non-DOT only

Number of CDL / covered employees:

Number of non-DOT employees to enroll:

Number of power units:

Primary Contact

First Name *

Last Name *

Title *

Contact Person Mobile *

Email *

Preferred contact method: *

Call

Email

Text

Billing contact (if different)

Billing Address - Full Name

Billing Address - Phone Number

Billing Address- Email

Current Program Status

Do you currently have a drug and alcohol testing program? *

Yes

No

Not Sure

common.other_option

If yes, current provider:

Contract end date, if known:

Do you have a written DOT drug and alcohol policy? *

Yes

No

Not Sure

Have you had an FMCSA audit or compliance review?

Yes-Date
No
Scheduled:

Are you a new entrant (USDOT number issued within 12 months)? *

Yes

No

Any current Clearinghouse violations among your drivers? *

Yes

No

Not Sure

Notes:

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