Fillable Application - Automobile Filing Questionnaire36-8959

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Application - Automobile Filing Questionnaire36-8959

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AUTOMOBILE FILING QUESTIONNAIRE
For prompt and reliable service, complete information must be provided, including the Exact Name,
Address and associated Docket Number for which the authority exists.
Failure to provide full and complete information may result in processing delays and possible
suspensions.
Applicant Name:
Policy Effective Date: Policy Number:
FILING INFORMATION
1.
Does the Applicant hold an ICC/ FMCSA permit or USDOT registration?
Yes
No
a.
If yes, provide:
MC #
PUC #
State(Case)#
2.
Is an MCS 90 endorsement needed?
Yes
No
3.
Does the Applicant require state filings?
Yes
No
a
If yes, list each state(s) and provide necessary state motor carrier number, if applicable.
4.
Provide the exact name and address as shown for filings, permits, etc.
Exact Name on Filing:
Exact Street Address on Filing:
City:
State:
Zip:
5.
Please provide copies of all required filings (i.e. local, state and/or federal).
SPECIAL INSTRUCTIONS
04.2018 ed.
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Application - Automobile Filing Questionnaire36-8959

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Completed 2 July 2020

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