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Form MC100(05/2014) Page 1 APPLICATION FOR WYOMING OPERATING AUTHORITY AS A COMMERCIAL MOTOR CARRIER FOR WYOMING DEPARTMENT OF TRANSPORTATION USE ONLY Docket Number $50.00 filing fee for NEW APPLICATION $50.00 filing fee for NAME CHANGE STEP #1 APPLICANT INFORMATION Personal name or Corp or LLC Name Trade Name or d/b/a Mailing Address City State ZIP Physical Address City State ZIP Phone Number Cell Number Fax Number Federal ID Number or SS Number U.S. DOT Number Email Address STEP #2 CARRIER INFORMATION (If you are applying for both Private and Contract, check both boxes.) A Private Carrier is any person engaged in business and operating a vehicle which has a gross vehicle weight exceeding 26,000 pounds who, without compensation, transports intrastate over state highways their employees or property of which the person is the owner, lessee or bailee, used in the furtherance of any commercial enterprise. A Contract Carrier is any person engaged in the intrastate transportation of people or property by motor vehicle on state highways for compensation. Private Carrier and/or Contract Carrier The applicant will transport: (Check all that apply.) Property Passengers House Trailer/Mobile Home Towing/Recovery Vehicle Wrecker Inspection (Required for Towing/Recovery Vehicles) The applicant will be the sole owner and in control of the transportation operations herein proposed; the applicant is: An Individual A Partnership A Limited Liability Company A Corporation If a corporation or an LLC, incorporated/organized under the laws of: The State of: Date of Incorporation/Articles of Organization: If the applicant is a Partnership, Association, or Corporation, list names of all partners or principle officers. Name Title Address STEP #3 Complete if seeking PRIVATE CARRIER AUTHORITY for UNITS IN EXCESS OF 26,000 LBS. GROSS VEHICLE WEIGHT (Hauling your own property or employees) Describe the nature or character of the business or commercial enterprise requiring the use of a motor vehicle and specifically list the commodities you intend to transport. (ie: company employees, company owned equipment, etc.) ---PAGE BREAK--- Form MC100(05/2014) Page 2 STEP #4 Complete if seeking a CONTRACT CARRIER AUTHORITY (INTRAstate contract hauling). Describe the nature or character of the business or commercial enterprise requiring the use of a motor vehicle and specifically list the commodities you intend to transport for compensation. (ie: passengers, rocks, equipment, etc.) If you are transporting people, list the number of passengers you can transport, including the driver for taxis, shuttles, or buses (fishing, hunting, or tour guides). NOTE: More than 9 passengers, including the driver, must have a USDOT INSURANCE REQUIREMENTS FOR CONTRACT CARRIER AUTHORITY: All Contract Carriers require liability insurance filings (Form E) prior to the authority being approved. The required amount of coverage of $500,000 combined single limit (CSL). That amount must be typed in the upper left corner of the Form E filing. Most Contract Carriers require cargo insurance filing (Form H) prior to the authority being approved. Cargo insurance is not required if the cargo that is transported has no appreciable salvage value. [ie raw agricultural products (except livestock), sand, (not in pneumatic trailers), rock, dirt, gravel. etc.] The required amount of coverage is $10,000. The amount (or greater, if more insurance is carried) must be typed in the upper left corner of the Form H filing. All Contract Carriers transporting mobile homes require cargo insurance filings (Form MC-61E) prior to the authority being approved. The minimum required amount of coverage is $5,000. Insurance underwriter fillings can be scanned, then attach to an email & send to: [EMAIL REDACTED] STEP #5 Please refer to W.S. 31-18-201 to determine Wyoming State Registration requirements for your vehicle(s). Refer to http://legisweb.state.wy.us/statutes/statutes.aspx?file=titles/Title31/T31CH18.htm. If you would like a copy of the Rules and Regulations Governing Motor Carriers, please access the internet at http://www.dot.state.wy.us/wydot/site/wydot/Motor_Carrier. Click on Chapter 1, Motor Carriers. If you do not have access to the Internet and need a copy of the Rules and Regulations, please call [PHONE REDACTED]. STEP #6 AFFIDAVIT I, the applicant, understand that filling of this application does not, in itself, constitute authority to operate. I agree to notify the Department of Transportation immediately of any changes of address, legal ownership, commodities transported operation or territory in the event this application is granted in whole or in part. I also understand the difference between being a Private Carrier and a Contract Carrier. I hereby certify that the information facts and statements made above are correct and acknowledge that false information could lead to revocation of any authority granted. Signature of Applicant Date Authorized Agent of Applicant (Please attach POA.) Date STEP #7 We accept Credit Cards, but account numbers & expirations MUST be called into our office [PHONE REDACTED]. For all Credit Card purchases, there will be a Vital Check handling fee of $2.50. If mailing application and sending check, make check payable to WYDOT in the amount of $50.00. BOTH pages 1 & 2 must be returned before Authority can be issued. Sign and date page 2 of this application. A fee of $50.00 is required for a name change. No fee for address update only. MAIL APPLICATION TO THE ADDRESS BELOW OR EMAIL APPLICATION TO [EMAIL REDACTED] Wyoming Department of Transportation, Regulatory Section 5300 Bishop Blvd. Cheyenne, WY 82009-3340 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED]