Fill - Free fillable Carrier Application New Mover (Commonwealth of Massachusetts) PDF form

Carrier Application – New

Household Goods Mover

- - - - -

Please note: a fee of $100 is required to process this application.

The Division now accepts payments online. Please visit our website for more information:

mass.gov/how-to/pay-transportation-oversight-division-fees

SECTION A - BACKGROUND INFORMATION

A1. Full Name(s) of Applicant, Partners, or Corporation:

A2. If doing business under a d/b/a, state the d/b/a:

A3. Principal place of business (P.O. Box # not acceptable):

Is this address a residence? Yes No

A4.Vehicle garaging point (P.O. Box # not acceptable):

Is this address a residence? Yes No

A5. Mailing address (if different from A3):

Is this address a residence? Yes No

A6. Contact information for person who can answer inquiries regarding this application:

A7. Does the applicant or any of its principals presently hold a certificate from this Department? Yes No

If so, state certificate number:

A8. Has the applicant or any of its principals ever held a certificate from this Department suspended or revoked?

Yes No

If so, state certificate number:

A9. Has the applicant or any of its principals ever held a license or certificate from any other state or federal

regulatory agency?

Yes No

Is so, identify:

Department of Public Utilities

Transportation Oversight Division

1 South Station, 5

Floor • Boston, MA 02110 • Tel: (617) 305-3559 • Fax: (617) 478-2598 • Email: DPU.Transportation@mass.gov

For DPU Use Only

Certificate Number:

A10. Indicate the type of business enterprise below and submit one copy of the required document with

this application. The document should

be identified as "Appendix A1”.

A11. If a partnership, list names and addresses of principal partners:

Name

Address

A12(a). If a corporation, list names, titles and addresses of officers:

Name

Title

Address

A12(b). If a corporation, list names and addresses of principal stockholders:

Name

Address

Type of Business

Document to be Submitted

An individual proprietorship

None

An individual proprietorship operating under a

d/b/a

A certified copy of the business certificate filed with the City/Town

Clerk

A partnership

A certified copy of the business certificate filed with the City/Town

Clerk

A corporation incorporated in the

Commonwealth of Massachusetts

A certified copy of the articles of organization from the

Massachusetts Secretary of State

A foreign corporation incorporated under the

laws of

A certified copy of foreign corporation approval to do business in

Massachusetts from the Secretary of State and a certified copy of

corporation papers from home state.

Attach using Adobe

Enter state of incorporation here

SECTION B – FITNESS

B1. Describe fully the transportation or other relevant work experience of applicant or its principals. (If

necessary, attach additional sheets and identify as "Appendix B1"):

B2. Provide information on the financial condition of the applicant/company to conduct a business. A current

balance sheet must be attached to this application and identified as "Appendix B2".

B3. (A) Has any license or certificate issued to applicant or any of its principals ever been

suspended or revoked by the United States Government, this State or any State or Territory?

Yes No

(B) Are there any charges or complaints now pending against applicant or any of its principals

before any court, regulatory body or government agency?

Yes No

"Appendix B3":

B4. Describe each of the motor vehicles owned or to be leased and operated by applicant in the service proposed. (If

necessary, attach additional sheets and identify as "Appendix B4"):

Year of

Manufacture

Type of Vehicle

Owned by

Applicant

To Be Leased

by Applicant

Name of

Manufacturer

Attach using Adobe

SECTION C – VERIFICATION

C1. Date

I hereby certify that the statements contained in this application herein made are full, just and true to the best of

my knowledge and belief. This statement is made under the penalties of perjury.

Signature (type full, legal name)

Title

C2. Date

Pursuant to G.L. c. 62C, Sec. 49A, I certify under the penalties of perjury that I, to my best knowledge and belief,

have filed all state tax returns and paid all state taxes required under law.

Signature (type full, legal name) of Applicant or type Corporate Name

Signature (type full, legal name) of Corporate Officer (if applicable)

(Applicant, Partner, Corporate Officer)

Please note: a fee of $100 is required to process this application.

Applications will not be processed without payment.

The Transportation Oversight Division now accepts payments

online. You can also submit a check or money order by mail.

Please see our website for more information:

mass.gov/how-to/pay-transportation-oversight-division-fees

Using Adobe Acrobat or Reader to fill out this application? Click the

red button below to submit your application by email. You can also

save this PDF and submit it as an email attachment to:

DPU.Transportation@mass.gov

You can also print and submit this application by mail to the

Transportation Oversight Division. The Division's mailing address can

be found at the top of this form. Please be sure to pay online or

submit a check/money order with your application.

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Carrier Application New Mover (Commonwealth of Massachusetts)

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