APPLICATION TO DISCONTINUE SERVICE
SECTION 1. GENERAL INFORMATION
USDOT NO. FEIN/SSN
NAME OF CARRIER
DOING BUSINESS AS (DBA) NAME
PRINCIPAL PLACE OF BUSINESS ADDRESS (not a PO Box) – STREET CITY
STATE ZIP CODE
MAILING ADDRESS (if different than Principal Address, may be a PO Box) – STREET CITY
STATE ZIP CODE
PERSON TO CONTACT CONTACT PHONE NO. FAX NO. E-MAIL ADDRESS
SECTION 2. TYPE OF AUTHORITY OR SERVICE TO BE DISCONTINUED
Passenger in Charter Service
Passenger in Other than Charter Service (attach copy of your certificate of authority.)
Household Goods (attach copy of your certificate of authority.)
SECTION 3. REASON FOR DISCONTINUANCE OF SERVICE
Intrastate only authority – Out of Business. Date company ceased business: _________________________________
Intrastate authority issued in conjunction with interstate passenger authority under 49 U.S.C. Section 10922. Attach
copy of the order issued by FMSCA authorizing discontinue of service.
Other: state specific reason with supporting facts for service discontinuance (attach additional documentation if
SECTION 4. INACTIVATION OF USDOT NUMBER
If your USDOT Number is classified as Intrastate Only, or if you obtained this USDOT Number solely for the purpose of
acquiring Missouri Intrastate Authority, you no longer need this number. Please indicate below if you would like our
office to inactivate your USDOT Number.
YES, please inactivate my USDOT Number.
NO, please leave my USDOT Number active.
SECTION 4. SIGNATURE
Under penalty of perjury under the laws of the State of Missouri and the United States of America, the information in
this application or attached hereto in true and correct, that I am authorized to sign this Application on behalf of the
Applicant and that the signature below is my own true and correct signature made by me or my legal representative
and by no other person. (Applicant(s)/Attorney Signature must be a physical signature)
Applicant(s)/Attorney Name Printed Applicant(s)/Attorney Signature
If Attorney signed on behalf of Applicant above, print address
Attorney MO Bar No.
MISSOURI DEPARTMENT OF TRANSPORTATION E-MAIL firstname.lastname@example.org
MOTOR CARRIER SERVICES PHONE 1.866.831.6277
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270 FAX 573.522.6708