COMPANY INFORMATION
SHEET
COMPANY INFORMATION:
Company Name (MUST MATCH INSURANCE) ___________________________
DBA_____________________________________________________________
Physical
Address________________________________________________
City__________________
State____ Zip________ County_____________
Mailing
Address_________________________________________________
City__________________
State____ Zip________ County_____________
DOT Number (if any) ___________________
Federal ID Number (tax number with IRS) ________________________
Telephone #'s:
Business (____) ____-______ Fax (___) ____-____
Home (___)
____-______ Other (____) ____-______
Ext: _________
How long have you been in business? _______Years _______Months
What is the name of your Process Agent Company? ________________
________________________________________________________________
QUESTIONS:
Do you want your applications sent overnight? _______Yes _____No
If yes, we will use our
Account # and bill you back for them!!
How many sets of permits (# of trucks) do you want? _____________
Do you want us to process your Fuel Tax reports? _____Yes ____No
TYPE OF OWNERSHIP:
Individual____ Partnership____ Corporation____
If
Individual: Full legal name!
First_______________
Middle_______________ Last__________________
Date of birth ____/____/____ Social Security #_____-_____-_______
If
Partnership: List all partners names & SS #'s below!
First_______________
Last___________________ SS#_____-_____-_____
First_______________
Last___________________ SS#_____-_____-_____
First_______________
Last___________________ SS#_____-_____-_____
If
Corporation: List officers names & SS #'s below!
President__________________________________
SS#_____-_____-_____
Vice
President_____________________________ SS#_____-_____-_____
Secretary__________________________________
SS#_____-_____-_____
Date
of Incorporation ____/____/____ Corporation #______________
State
of
TYPE OF COMPANY: (check
one or more of the following)
Private (hauls OWN commodities)_________ FHWA Exempt _______
FHWA Common______ FHWA Contract_______
If you have FHWA authority, what is your FHWA MC #__________________
Will you be hauling hazardous materials __________________________
INSURANCE INFORMATION:
Agents Name_____________________ Phone (____) _____-______
Ext___
Name of Ins.
company______________________________________
Signature_____________________________ Date____/____/____
Contact person with YOUR company__________________________________