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1
FORM MO-1 – APPLICATION TO OPERATE IN INTRASTATE COMMERCE
IT IS STRONGLY RECOMMENDED THAT YOU USE THE INSTRUCTIONS PROVIDED WITH THIS FORM AS A
GUIDE. INCOMPLETE OR INCORRECT APPLICATIONS WILL DELAY THE ISSUANCE OF AUTHORITY.
SECTION 1. TYPE OF REQUEST
A. APPLICANT REQUESTS APPROVAL FOR NEW OR ENLARGED AUTHORITY AS A (check all that apply)
COMMON CARRIER (Haul for general public) CONTRACT CARRIER (Named company/companies only – Attach copy of contract)
B. TO TRANSPORT WHOLLY WITHIN ALL POINTS IN MISSOURI (check all that apply)
PROPERTY (Excluding Household Goods or Passengers)
HOUSEHOLD GOODS Temporary Authority (Urgent need must be shown)
PASSENGERS OTHER THAN IN CHARTER SERVICE Temporary Authority (Urgent need must be shown)
PASSENGERS IN CHARTER SERVICE
PASSENGERS OTHER THAN IN CHARTER SERVICE AS A NOT-FOR-PROFIT CORPORATION (check all that apply)
Elderly
Handicapped
Preschool disadvantaged children transported for the purpose of participating in the federal Head Start Program.
Passengers transported in areas other than “urbanized areas,” to be subsidized or reimbursed under section 18 of the Urban Mass
Transportation Act of 1964, as amended, section 5311 of title 49 USC, with federal funds administered by MoDOT.
HAZARDOUS MATERIALS
C. APPLICANT REQUESTS MODOT TO APPROVE A TRANSFER OF
ALL INTRASTATE AUTHORITY A PORTION OF INTRASTATE AUTHORITY (Attach Exhibit 1C describing authority to be transferred)
USDOT NO. NAME OF CARRIER
Transferor(s) Name Printed
Transferor(s) Signature
Title
Date
SECTION 2. GENERAL INFORMATION
USDOT NO.
FEIN/SSN (SSN Sole Proprietor Only)
NAME OF CARRIER
DOING BUSINESS AS (DBA) NAME
PRINCIPAL PLACE OF BUSINESS ADDRESS (Not a PO Box) - STREET
STATE
ZIP CODE
MAILING ADDRESS (if different than Principal Address) - STREET
STATE
ZIP CODE
MISSOURI TERMINAL ADDRESS (If any) - STREET
STATE
ZIP CODE
PERSON TO CONTACT
CONTACT PHONE NO
FAX NO
E-MAIL ADDRESS
SECTION 3. FORM OF BUSINESS
Sole Proprietor Partnership Limited Partnership Limited Liability Partnership Limited Liability Company Corporation Trust
STATE OF ORGANIZATION/INCORPORATION DATE ORGANIZED CHARTER NO
NAME OF COMPANY OFFICERS OR PARTNERS (Please Print)
TITLE
SECTION 4. PUBLIC LIABILITY SECURITY – INSURANCE
Applicant is required to file proof of insurance to the limits of liability prior to issuance of authority. See Instructions for insurance required.
CONTACT YOUR INSURANCE COMPANY TO FILE THE REQUIRED INSURANCE FORM(S) WITH MoDOT.
SECTION 5. REGISTERED AGENT FOR SERVICE OF PROCESS IN MISSOURI
If the state of your principal place of business (as shown above) is NOT Missouri, you must provide a person’s name and physical address (not a PO
Box) in Missouri where legal documents may be accepted on your behalf.
Name and Address:
MISSOURI DEPARTMENT OF TRANSPORTATION
E-MAIL:
contactmcs@modot.mo.gov
MOTOR CARRIER SERVICES
PHONE:
1.866.831.6277 Option 3
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
FAX:
573.522.6708
2
SECTION 6. REGULATORY LICENSE FEES (Not Required for Not-for-Profit Corporations)
Applicant will need to purchase door decals or window decals. (See instructions for decal type and payment options)
(number) (number)
Applicant has interstate authority and has/will pay regulatory fees under the Unified Carrier Registration (UCR) program.
SECTION 7. HAZARDOUS MATERIALS (Required ONLY for Hazardous Materials Applicants)
APPLICANT WILL TRANSPORT HAZARDOUS MATERIALS REQUIRING:
$1 Million in Public Liability & Property Damage in accordance with 4 CSR 265-10.030; OR
$5 Million in Public Liability & Property Damage in accordance with 4 CSR 265-10.030
APPLICANT DESIRES TO TRANSPORT THE FOLLOWING HAZARD CLASSES/DIVISIONS: (Check ALL that apply)
(If you transport ALL divisions within a class check the box titled “All Divisions”)
CLASS 1 EXPLOSIVES: ALL Divisions of Class 1 Explosives
Division 1.1 Explosives that have a Mass Explosion Hazard
Division 1.2 Explosives that have a Projection Hazard
Division 1.3 Explosives that have a Fire Hazard and either a Minor Blast Hazard or a Minor Projection Hazard, or both
Division 1.4 Explosive Devices that present a Minor Blast Hazard
Division 1.5 Very Insensitive Explosives
Division 1.6 Extremely Insensitive Detonating Substances
CLASS 2 GASSES: ALL Divisions of Class 2 Gasses
Division 2.1 Gasses that are Flammable
Division 2.2 Gasses that are Non-Flammable and Compressed
Division 2.3 Gasses that are Poisonous
CLASS 3 FLAMMABLE AND COMBUSTIBLE LIQUIDS
CLASS 4 FLAMMABLE SOLIDS: ALL Divisions of Class 4 Flammable Solids
Division 4.1 Solids that are Flammable
Division 4.2 Material that is Spontaneously Combustible
Division 4.3 Material that is Dangerous When Wet.
CLASS 5 OXIDIZERS AND ORGANIC PEROXIDES: ALL Divisions of Class 5 Oxidizers and Organic Peroxides
Division 5.1 Oxidizers
Division 5.2 Organic Peroxides
CLASS 6 POISONS: All Divisions of Class 6 Poisons
Division 6.2 Material that is an Infectious Substance (Etiologic Agent)
Division 6.1 A Poison Liquid which is a PIH Zone A
Division 6.1 B Poison Liquid which is a PIH Zone B
Division 6.1 Poison, Poisonous Liquid with no inhalation hazard
Division 6.1 Solid, Poison which is a solid
CLASS 7 RADIOACTIVE MATERIALS
CLASS 8 CORROSIVES
CLASS 9 MISCELLANEOUS
ORM-D (Other Regulated Materials)
SECTION 8. SAFETY COMPLIANCE & SIGNATURE (An Attorney is NOT required to sign the application on behalf of a Corporation)
Commercial motor vehicle safety regulations apply to motor carriers operating in intrastate commerce. For more information about Safety
regulations that apply to your operation visit the Safety & Compliance section of our website at www.modot.org/mcs.
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 is true, correct and complete to the best of my knowledge, I am authorized to sign this application on behalf of the applicant and 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 Name Printed
Applicant(s)/Attorney Signature
Title
Date
If Attorney signed on behalf of Applicant above, print address
Attorney MO Bar No.
3
CONTINUE THIS APPLICATION ONLY IF YOU HAVE CHECKED BOX 2, 3, 4 OR 5 UNDER SECTION 1B
SECTION 9. VERIFICATION OF WORKERS’ COMPENSATION (Required ONLY for Household Goods)
Applicant certified that it is COMPLIANT with RSMo 287 by procuring workers’ compensation insurance coverage for its employees.
Applicant has permission from the Division of Workers’ Compensation to SELF-INSURE its liabilities.
Applicant has less than five employees (defined as full and part-time, seasonal, and temporary employees) and is EXEMPT from procuring
workers’ compensation coverage.
NOTE: If your company is required to obtain workers’ compensation insurance coverage and coverage lapses or is discontinued, any household
goods authority issued pursuant to this application is subject to suspension until compliance is met.
SECTION 10. LIST OF APPLICANT’S EQUIPMENT TO BE USED
TYPE OF VEHICLE
MODEL YEAR
MAKE
SEATING CAPACITY
(EXCLUDING THE
DRIVER) OF
PASSENGER
VECHICLES OR
LICENSED WEIGHT
OF OTHER VEHICLES
REASONABLE VALUE
SPECIFY WHETHER
VEHICLE IS OWNED,
LEASED, OR TO BE
ACQUIRED
CHECK IF
EQUIPMENT WILL BE
USED TO HAUL
HAZARDOUS
MATERIALS
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Attach list if needed for additional equipment – Name Exhibit 10 at top of each additional page.
SECTION 11. STATEMENT OF RATES TO BE CHARGED (Not Required for Household Goods)
TYPE OF RATE TO BE CHARGED (check all that apply)
PER PASSENGER – If you charge a per passenger fee you should choose Passengers Other than in Charter Service in Section 1.
GROUP – If you charge a group rate you should choose Passengers in Charter Service in Section 1.
Please provide below a statement of the rates to be charged if authority is granted for the transportation of passengers in intrastate commerce.
Rates and charges might include minimum rate, rate per hour per vehicle type, rate per passenger (if applicable), seasonal rates or other
information that is specific and clear. For charter operations, the rates and charges must be for the use of the vehicle and cannot be a per
passenger charge.
HOUSEHOLD GOODS – Applicant must prepare a tariff after the authority is granted, but prior to start of business. The tariff will not be required to
be filed with Motor Carrier Services. See state regulation 7 CSR 265-10.050 for how to prepare a household goods tariff or request a copy of a
sample tariff. The tariff will be required to be posted in each terminal. You will be required to charge customers only those rates and charges in
your tariff in effect at the time of the movement as provided in the tariff.
TRANSPORTING PASSENGERS OTHER THAN CHARTER SERVICE – If you do not have interstate authority, you will be required to file your rates and
charges with Motor Carrier Services in the form of a tariff prior to the grant of authority. Our agency will contact you at the time the application is
ready to be issued.
4
SECTION 12. FINANCIAL FITNESS This section is required for: HOUSEHOLD GOODS APPLICANTS ; PASSENGER OTHER THAN CHARTER APPLICANTS; CHARTER
APPLICANTS WITH CAPACITY OF LESS THAN 16 PASSENGERS
A. BALANCE SHEET (Copy this sheet as needed)
If applicant is an individual partnership, complete Column A. For Partnerships, also complete a balance sheet for each partner. If applicant is a
corporation or limited liability company, complete Columns A & B.
The Balance Sheet and Income Statement (Columns A & B) must be completed on a calendar year basis (January 1 through
December 31). Column B reflects actual data for the current calendar year OR for new corporations just starting business. If
you are an existing business and do not have any actual current year data available to report, please note N/A in this column.
You may add, by attachment, supplemental information to this financial statement if you feel it will help support the
application. Additional information may also be requested by our agency if your financial statement appears incomplete or
questionable.
(A)
For Year
Ending
(Month/Year)
_____ _____
(B)
Current Year
Ending
(Month/Year)
_____ _____
1. TOTAL CURRENT ASSETS
Include cash in checking and savings; amounts due from others; prepaid insurance, taxes, or other payments;
cost of materials and supplies on hand; and other near cash assets.
$
$
2. OTHER ASSETS
Include trucks, trailers (or buses) and other equipment shown in Section 10 above, minus depreciation; and
other property.
$
$
3. TOTAL ASSETS (Add lines 1 and 2 above)
$
$
4. TOTAL CURRENT LIABILITIES
Include any amount due to others within 1 year or less on any loans, accounts due, or other debt.
$
$
5. TOTAL LONG TERM LIABILITIES
Include any amount due to others after 1 year on any loans, accounts due, or other debt.
$
$
6. CAPITAL STOCK (Corporations only)
$
$
7. RETAINED EARNINGS, CONTRIBUTED CAPITAL, OR EQUITY OF LIMITED COMPANIES (Corporations only)
$
$
8. NET WORTH-PARTNERS OR INDIVIDUALS
$
$
9. TOTAL LIABILITIES AND EQUITY (Add Lines 4 through 8)
$
$
B. PRO-FORMA BALANCE SHEET
If applicant is a partnership, corporation, or limited liability company, check only one box below and provide information if needed.
In order to provide the proposed service if this authority is granted, applicant does NOT intend to acquire any additional assets or liabilities.
In order to provide the proposed service if this authority is granted, applicant does intend to purchase additional assets or incur additional
liabilities as follows:
(Include a description of the items, the amount of the purchase and any associated debt or loan amount)
C. INCOME AND EXPENSE STATEMENT
WAGE EARNER ONLY (IF CHECKED, DO NOT COMPLETE LINES 1-5 BELOW)
(A)
For Year
Ending
(Month/Year)
_____ _____
(B)
Current Year
Ending
(Month/Year)
_____ _____
1. TOTAL REVENUE
Include all sales/revenue minus any costs of goods sold.
$
$
2. TOTAL EXPENSES
Include all operating expenses such as salaries and fringes, depreciation, insurance, repairs, fuel and oil, tires,
office, and other expenses, insurance, utilities, rent paid for vehicles or office equipment, operating taxes and
licenses, legal and professional fees and other expenses.
$
$
3. NET OPERATING REVENUE (Line 1 minus Line 2)
$
$
4. OTHER OPERATING INCOME AND EXPENSES
Include mortgage or other interest expense; and gain (or loss) on sale of assets
$
$
5. NET INCOME (OR LOSS) (Line 3 minus Line 4)
$
$
5
MO-1 FORM INSTRUCTIONS
SECTION 1 – TYPE OF REQUEST
A. TYPE OF CARRIER – Check the box that represents Common Carrier or Contract Carrier. If contract carrier, attach a copy of the contract.
B. TYPE OF AUTHORITY – J Check all boxes that apply to the type of authority being requested.
Property
Authorization to transport property, except household goods and passengers.
THIS INCLUDES HAZARDOUS MATERIALS – if hauling hazardous materials, also check Hazardous
Materials.
Household Goods
Authorization to transport personal effects and property to be used in a dwelling, store, office, or
institution; or articles that require specialized handling and equipment used in moving household goods.
Passengers Other than in Charter
Service
Authorization to transport passengers for-hire at a per passenger fee.
Passengers in Charter Service
Authorization to transport passenger groups from a point of origin to a predetermined destination at a
fixed charge for the vehicle (charges are usually per mile or per hour and are paid in a single amount to the
carrier for the entire group).
Passengers Other than in Charter
Service – Not-For-Profit
Check the box to indicate the type of not-for-profit corporation.
C – TRANSFER OF AUTHORITY – A Transfer of Authority indicates a change in ownership or type of business (e.g. Joe Smith is now MO Carrier LLC).
Indicate if the transfer is full or partial (if partial, attach a description of the portion of authority to be transferred and title it Exhibit 1C). Be sure to
include the USDOT number and Name of Carrier transferring authority. The Name of the Carrier is the company name or legal name registered with
the Missouri Secretary of State.
A corporation that has sold its stock, but has not dissolved, liquidated, or merged with another corporation has not changed its legal form so a
Transfer of Authority is NOT required.
Interstate carriers must also complete the transfer with the Federal Motor Carrier Safety Administration. Information can be verified at
www.safer.fmcsa.dot.gov.
Companies with apportioned license plates (IRP) and/or a fuel tax license (IFTA) must update information with those programs to receive new
cab cards and/or an IFTA license in the new name. This may require submission of new titles and/or leases.
When requesting a transfer, a signature is required in this section and in Section 8 on page 2 before the application can be processed.
SECTION 2 – GENERAL INFORMATION
USDOT Number – A USDOT number is required for operation in intrastate commerce in the state of Missouri. A USDOT number can be obtained at
www.fmcsa.dot.gov/registration.
FEIN Number/Social Security Number – An FEIN number is a federal Tax ID number. A sole proprietor who does not have an FEIN number should
enter a Social Security Number.
Legal Name – This is the Company name or Legal Name registered with the Missouri Secretary of State. This name MUST be the same as the name
registered with the FMCSA and the Missouri Secretary of State’s Office, if applicable.
Doing Business As (DBA) Name – A DBA is a name that a company may use that is different from their legal company name. If using a DBA name, it
MUST be registered with the Missouri Secretary of State. Fictitious name registrations can be filed online at https://www.sos.mo.gov or by calling
1.866.223.6535.
Principle Place of Business – The Principle Place of Business address is the location where the safety records of the company are kept or can be
made available. This must be a physical location, not a PO Box.
Mailing Address – Enter the mailing address if different than the principal place of business address. This address may be a PO box.
SECTION 3 – FORM OF BUSINESS
A. BUSINESS TYPE – Check the box that represents the type of business. This MUST be the same as the type of business registered with the
Missouri Secretary of State.
B. OUT OF STATE ORGANIZATION – Provide the state where the business is organized, if other than Missouri.
C. COMPANY OFFICERS – List the company’s officers, partners, or members and their titles. This is not required for sole proprietors.
SECTION 4 – PUBLIC LIABILITY SECURITY-INSURANCE
The company’s insurance company must file the required insurance forms BEFORE authority can be granted.
This form must include: Motor Carrier Name, DBA Name (if applicable), Business Address as reflected in Section 2.
THIS MUST BE THE SAME AS THE NAME REGISTERED WITH THE FMCSA AND THE MISSOURI SECRETARY OF STATE.
6
COMMODITY TRANSPORTED
AMOUNT OF REQUIRED COVERAGE
FORM TO FILE
Non-hazardous Property & Household Goods
$100,000 for any injury or death of one person
$300,000 for any one accident
$50,000 property damage for any one accident
Form E
or
Form G
Hazardous Property
$1 million or $5 million dependent upon hazard class(es)/division(s)
being transported. To determine exact liability coverage, please call
MoDOT-MCS.
Form E
or
Form G
Cargo (only required for Household Goods)
$2,500 for loss or damage to property carried on any one motor vehicle.
$5,000 for loss or damage to, or aggregate of losses or damages of or to
property, occurring at any one time or place.
Form H
or
Form J
SECTION 5 – REGISTERED AGENT FOR SERVICE OF PROCESS IN MISSOURI
If the principal place of business is NOT in Missouri the name and address of a process agent based in Missouri where service can be made on the
business MUST be provided. This must be the name of an individual, not an organization, and the address must be a physical location, not a PO Box.
The FMCSA provides a list of some process agents on their website at www.fmcsa.dot.gov/registration/process-agents.
For corporations located in Missouri, any officer listed in Section 3C may be used as the registered agent unless another individual is specified.
SECTION 6 – REGULATORY LICENSE FEES (not required for not-for-profit corporations)
Check the box that represents if a door or window decal is needed, or if fees are paid under the Unified Carrier Registration program.
Intrastate Carriers – must purchase either door or window decals for each vehicle. Note: Window decals are for passenger service with 6 to 12
passenger capacity only.
Decals are $10 per vehicle, and payment must be received before authority is issued.
Interstate Carriers – must pay fees through the Unified Carrier Registration program and are not required to purchase or display Intrastate decals.
SECTION 7 – HAZARDOUS MATERIALS
Check the box that indicates the type of insurance required and what class and division of hazardous materials are transported. If ALL divisions
within a class are transported, check the box titled “All Divisions”.
The classes and divisions listed MUST be registered with the FMCSA. If objects powered by a flammable liquid including, but not limited to
motor vehicles are transported, Class 9 – Miscellaneous must be chosen.
SECTION 8 – SIGNATURE
The signature of the applicant is required before processing the application. If someone other than the applicant signs, proof of Power of Attorney
is required.
If requesting a transfer, a signature is required in Section 1 on page 1 and in this section before the application can be processed.
Corporate officers may sign on behalf of the corporation, and a Member or Manager of an LLC may sign on behalf of the business.
Complete Section 9-12 ONLY if box 2, 3, 4 or 5 in Section 1B are checked
SECTION 9 – VERIFICATION OF WORKERS COMPENSATION (only required for Household Goods applicants)
Check the box that represents COMPLIANT, SELF-INSURED, or EXEMPT from obtaining workers compensation coverage.
Any lapse or discontinuation of service will result in a suspension of authority.
SECTION 10 – EQUIPMENT TO BE USED
List all power units or equipment used. Be sure to indicate if the equipment will transport hazardous materials.
Household Goods Carriers – list the Licensed Weight of the vehicle.
Passenger Carriers – List the Seating Capacity of the vehicle.
SECTION 11 – STATEMENT OF RATES (only required for Passenger applicants)
Provide a description of how rates will be charged.
Household Good Carriers – must complete a formal tariff AFTER authority has been granted, but before operations begin. The tariff must be
available for review at each terminal.
Passenger-Other-Than-Charter Carriers – intrastate carriers must file a formal tariff with MoDOT Motor Carrier Services BEFORE the issuance of
authority. Interstate Passenger-Other-Than-Charter carriers are NOT required to file a tariff with MoDOT.
SECTION 12 – FINANCIAL FITNESS
Fill out the appropriate information as indicated below if applying for Household Goods, Passenger Other than Charter, or Passenger Charter
authority with a seating capacity of less than 16 passengers.
Sole Proprietor or Partnership: complete column A. Partnerships must also complete a balance sheet for each partner.
Limited Liability Company or Corporation: complete columns A & B.
This section is not required for Property, Passenger Other than Charter as a Not-for-Profit Corporation, or Passenger in Charter authority with a
seating capacity of 16 or more passengers.
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MO-1 Form - Application To Operate Intrastate MO-iPad And IPhone Compatible

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Completed 20 July 2020

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