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MISSOURI DEPARTMENT OF TRANSPORTATION
PHONE: 573.751.3358
MOTOR CARRIER SERVICES
FAX: 573.751.0916
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
TOLL FREE: 866.831.6277
CHANGE OR ADDITION OF COMPANY CONTACT
In order to request a change or addition of company contact, the requestor must be authorized on the account to make
changes. In order for this form to be valid it must be signed by an authorized company official and notarized by an
individual appointed and commissioned as a notary public in the state of Missouri.
SECTION 1. CUSTOMER TYPE (Select all that apply)
IRP IFTA
SECTION 2. COMPANY INFORMATION
NAME OF CARRIER
NAME OF COMPANY CONTACT AUTHORIZED TO MAKE CHANGES
USDOT NO (IF APPLICABLE)
IRP NO
SECTION 3. ADD CONTACT
Add the following contact person to the account listed above:
PERSON TO CONTACT
PHONE NO
FAX NO
E-MAIL ADDRESS (*ONLY ONE E-MAIL ADDRESS IS ALLOWED PER ACCOUNT*)
*Additional contacts may be added using a separate sheet.
SECTION 4. REMOVE CONTACT
Remove the following contact person from the account listed above:
PERSON TO CONTACT
*Additional contacts may be removed using a separate sheet.
SECTION 5. SIGNATURE
Date
SECTION 5. NOTARY PUBLIC
NOTARY PUBLIC EMBOSSER SEAL OR
BLACK INK RUBBER STAMP
STATE OF
COUNTY (OR CITY OF ST LOUIS)
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
YEAR
USE RUBBER STAMP BELOW
NOTARY PUBLIC SIGNATURE
MY COMMISSION EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
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