Carrier Application New
Household Goods Mover
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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
th
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
An individual proprietorship
An individual proprietorship operating under a
d/b/a
A partnership
A corporation incorporated in the
Commonwealth of Massachusetts
A foreign corporation incorporated under the
laws of
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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
(C) If you answered yes to any of the above, please describe in detail below or on an attachment identified as
"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
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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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