Department of RevenueMotor Vehicle Division

1200 Tradport Blvd., Hapeville, GA 30354P.O. Box 161227, Atlanta, GA 30321(404) 675-6135 Fax: (404) 675-6196

Application for Motor Carrier Identification NumberForm MCS-150 GA

(PLEASE NOTE: THIS APPLICA TION IS FOR OPERA TING IN GEORGIA ONLY)

1. Name of Carrier 6. Doing Business As (DBA) Name (If any)

2. Physical Street Address or Route Number 7. Mailing Address (Such as P.O. Box)

3. City 4. State 5. Zip Code (Zip + 4) 8. City 9. State 10. Zip Code (Zip +4)

12. Phone Number

( )11. County 13. Georgia MCA# (If Known~ 14. U.S. DOT# (If updating) 15. ICC MC# (If Known)

(Note: N/A if GA. Only)

16. IRS Tax NumberorssN

EIN

17. E-mail Address 18. Carrier Mileage (Total Fleet Mileage LastCalendar Year)SSN

19. Carrier Operation

A. Georgia Only (Hazardous Materials) B. Georgia Only (Non-Hazardous Materials)

20. Operation Classification

A. Authorized For Hire

B. Exempt For Hire

C. Private (Property)

D.E.

F.

G. U.S. Mail

H Federal Gov!.

I. State Gov!.

J.K.

L.

Local Government

Indian Tribe

Other (Specify):.

Private Passengers (Business)

Private Passengers (Non-Business)

Migrant Workers

21. Cargo Classifications (Please Circle All That Apply)

A. General Cargo G. Building Materials

B. Household Goods H. Mobile Homes

C. Metal Sheet/Coil/Roll I. Machinery

D. Motor Vehicles J. Fresh Produce

E. DriveawayfTowaway K. Liquid/Gases

F. Logs, Poles, Beams, Lumber

DD. OtherL. Intermodal Containers

M. Passengers

N. Oil Field Equipment

O. Livestock

P. Grain, Feed, Hay

Q. Coal/Coke

X. Beverages

Y. Paper Products

Z. Utility

AA. Farm Supplies

BB. Construction

CC. Water Well Drilling

R. Meat

S. Garbage/Refuse

T. U.S. Mail

U. Chemicals

V. Dry Bulk Commodities

W. Refrigerated Food

B

B

NB

NB

B

B

B

NB

NB

NB

22. Hazardous Materials Carrier (Please Circle all thai Apply) B = Bulk packages (e.g. tanks, totes, etc.) NB = In Packages (e.g. drums, boxes, cylinders, etc.)

Explosives Flammable LIquids RadioactiveA. Div.1.1 B NB P. Class 3 B NB DD. Class 7

B. Div.1.2 B NB Q. Class 3A B NB EE. Hwy. Rte. Coni. Qty.

C. Div.1.3 B NB R. Class 3B B NB Corrosives

D. Div.1.4 B NB S. Combustible LIquid B NB FF. Class 8

E. Dlv.1.5 B NB Flammable Solids GG. Class 8A

F.Div.1.6 B NB T.Div.4.1 B NB HH.Class8B

Gases U. Div.4.2 B NB Other

G. Div. 2.1 B NB V. Div.4.3 B NB II. Class 9

H. Div. 2.1 LPG B NB Oxidizers/Organic Peroxides B NB JJ. Elevated Temp. Materials

I. Div. 2.2 B NB W. Dlv. 5.1 B NB KK. Infectious Waste

(Methane) X. Div.5.2 B NB LL. Marine Pollutants

J. Div.2.2 B NB Poisons/Etiologic Agents MM. Haz. Substances (RQ)

K. Div.2.2 B NB Y. Div.6.2 B NB NN. Hazardous Waste

(Ammonia) Z. Div.6.1A B NB OD. ORM.D

L.Div.2.3A B NB AA.Dlv.6.1B B NB

M. Div. 2.3C B NB BB. Div. 6.1 LIquid B NB

N. Div. 2.3C B NB CC. Div. 6.1 Solid B NB

O. Div. 2.3D B

B

B

B

B

B

B

B

NB

NB

NB

NB

NB

NB

NBNB

NB

NB

NB

23. Equipment TotalIStraight Trucks

TotalTruck Tractors

Total TotalTrailers HazMat Cargo

Tank Trucks

Passengers

Motor Coach School Bus LimousineOwned

Term Leased

Trip Leased

24. Number of Drivers Subject to the Motor Carrier Safety and/or HazMat Regulations

100 Mile Radius

Beyond 100 Mile Radius Total Drivers. Total CDL Drivers