Fillable APPLICATION FOR MOTOR CARRIER ACCOUNT (Oregon)

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APPLICATION FOR MOTOR CARRIER ACCOUNT (Oregon)

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OREGON DEPARTMENT OF TRANSPORTATION
COMMERCE AND COMPLIANCE DIVISION
3930 FAIRVIEW INDUSTRIAL DR SE
SALEM OR 97302-1166
PH (503) 378-6699
FAX (503) 378-6880
APPLICATION FOR MOTOR CARRIER ACCOUNT
SEE INSTRUCTIONS ON REVERSE
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK
TYPE OF APPLICATION
CCD ACCOUNT NUMBER NAME OF CARRIER
DOING BUSINESS AS (DBA)TELEPHONE NUMBER FAX NUMBER
CARRIER MAILING ADDRESS
CARRIER STREET ADDRESS (IF DIFFERENT THAN ABOVE)
POWER OF ATTORNEY - ATTACH COPY
CITY
CITY
CITY
STATE
STATE
STATE
ZIP CODE
ZIP CODE
ZIP CODERECORDS LOCATION ADDRESS
TRUCKING ONLINE CONTACT PHONE
TRUCKING ONLINE CONTACT PERSONEMAIL ADDRESS FOR TRUCKING ONLINE
TYPE OF OWNERSHIP AND FEDERAL TAXPAYER ID# (FEIN)
INDIVIDUAL PARTNERSHIP
CORPORATION:
IF FOREIGN BASED, ATTACH CORPORATE CERTIFICATE SHOWING DATE OF INCORPORATION AND CORPORATE STATUS.
LIMITED LIABILITY COMPANY - ATTACH A COPY OF THE ARTICLES OF ORGANIZATION
OTHER - PROVIDE TYPE OF OWNERSHIP:
DATE OF INCORPORATION:
TYPE OF OPERATION OR AUTHORITY - CHECK ALL THAT APPLY
PRIVATE CARRIER (NOT FOR HIRE) OREGON BASED
PRIVATE CARRIER (NOT FOR HIRE) BASED OUTSIDE OREGON
7W (SEE DESCRIPTION ON REVERSE)
(Description)
CLASS B FOR-HIRE LOCAL CARTAGE OF HOUSEHOLD GOODS WITHIN DESIGNATED
AREAS, PURSUANT TO ORS 825.240. A $50 APPLICATION FEE IS REQUIRED.
CLASS 1A PERMIT FOR-HIRE INTRASTATE COMMODITIES (EXCEPT HOUSEHOLD GOODS)
(COMPLETE ODOT FORM 735-9745)
INTERSTATE CARRIER (FOR HIRE)
USDOT NUMBER
MC EXEMPT OPERATIONS
MC AUTHORITY NUMBER
OREGON PROCESS AGENT
ADDRESS
PROVIDE FULL LEGAL NAME, TITLE, DATE OF BIRTH, AND SOCIAL SECURITY NUMBER OF INDIVIDUAL, ALL PARTNERS, CORPORATE OFFICERS, MANAGERS/MEMBERS OF LLC, GENERAL
PARTNER OF A LIMITED PARTNERSHIP, PARTNERS IN A LIMITED LIABILITY PARTNERSHIP. IF MORE THAN 3 PARTNERS, ATTACH SIGNATURE ADDENDUM FORM, 735-9075a.
LAST
DATE OF BIRTHSOCIAL SECURITY NUMBERTITLEMIDDLEFIRSTLAST
DATE OF BIRTHSOCIAL SECURITY NUMBERTITLEMIDDLEFIRSTLAST
FIRST MIDDLE TITLE SOCIAL SECURITY NUMBER DATE OF BIRTH
DISCLOSURE: THE DEPARTMENT IS AUTHORIZED TO VERIFY ANY OF THE INFORMATION GIVEN AND OBTAIN CREDIT REPORTS ON YOU AND/OR YOUR COMPANY. YOU AUTHORIZE THE
DEPARTMENT TO OBTAIN INFORMATION FROM OTHERS TO INVESTIGATE YOU AND/OR YOUR COMPANY'S CREDIT.
CERTIFICATION: THIS CERTIFICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT ORS 803.375 MAKES IT A CRIME TO KNOWINGLY PROVIDE FALSE
INFORMATION RELATED TO A VEHICLE REGISTRATION. ORS 803.385 MAKES IT A CRIME TO AFFIRM OR CERTIFY ANY INFORMATION RELATED TO A VEHICLE REGISTRATION THAT THE
PERSON KNOWS TO BE FALSE. EACH OFFENSE IS A CLASS A MISDEMEANOR AND EACH IS PUNISHABLE BY A JAIL SENTENCE OF UP TO ONE YEAR, A FINE OF UP TO $6,250, OR BOTH.
SIGNATURE REQUIREMENTS: MUST BE SIGNED BY OWNER; ALL PARTNERS; CORPORATION OFFICER; MANAGER/MEMBER OF LIMITED LIABILITY COMPANY (LLC), PARTNER IN A
LIMITED LIABILITY PARTNERSHIP OR AGENT. FAXED AND ELECTRONIC SIGNATURES ACCEPTABLE.
SIGNATURE
DATEPRINTED NAMESIGNATURE
DATEPRINTED NAMESIGNATURE
PRINTED NAME DATE
DO NOT WRITE BELOW THIS LINE. ODOT USE ONLY
PLEASE MAKE AND RETAIN A COPY FOR YOUR RECORDS
FORM 735-9075 (3-20) STK # 320069
ACCOUNT AMENDMENTADDRESS/PHONE/EMAIL CHANGENAME CHANGENEW CARRIER OWNERSHIP CHANGE
LIST PREVIOUS ACCOUNT NUMBERS
CONSORTIUM NAME
MOTOR CARRIER LEGAL NAME AND ADDRESS OF RECORD
ACCOUNTS WITH OREGON-BASED VEHICLES: PROVIDE NAME OF DRUG AND ALCOHOL TESTING CONSORTIUM IN WHICH
YOUR COMPANY IS ENROLLED OR WRITE “IN-HOUSE” IF YOU MAINTAIN YOUR OWN PROGRAM. TESTING PROGRAMS MUST BE
IN COMPLIANCE WITH USDOT REQUIREMENTS (49 CFR PART 382).
YOU WILL BE SENT A PIN FOR TRUCKING ON LINE ACCESS AT THE EMAIL ABOVE. I UNDERSTAND MY PIN CAN BE USED TO CONDUCT TRANSACTIONS WITH AND TO OBTAIN CREDENTIALS FROM ODOT OVER THE INTERNET. I
WILL TAKE STEPS TO PROTECT MY PIN FROM BEING ACCESSED BY UNAUTHORIZED USERS. I FURTHER UNDERSTAND THAT IF I GIVE MY PIN TO ANYONE ELSE, OR IF I AUTHORIZE A POWER OF ATTORNEY TO OBTAIN MY PIN
ON MY BEHALF, I AM PERSONALLY LIABLE FOR ANY TRANSACTIONS MADE OR CREDENTIALS OBTAINED BY ANYONE ELSE WHO MAY HAVE RECEIVED MY PIN FOR THE THIRD PARTY TO WHOM I ORIGINALLY DISCLOSED IT.
ONLY ONE EMAIL ADDRESS PER ACCOUNT. ONLY ONE PIN IS ALLOWED PER ACCOUNT.
TELEPHONE NUMBER
POA ADDRESS
FAX NUMBER EMAIL ADDRESS NAME OF AGENT
CITY STATE ZIP CODE
STATE OF INCORPORATION:
ENTERED BY/OFFICE:
DATE
I FURTHER CERTIFY KNOWLEDGE OF APPLICABLE FEDERAL AND STATE SAFETY RULES, REGULATIONS, STANDARDS AND ORDERS AND DECLARE ALL OPERATIONS WILL BE
CONDUCTED IN COMPLIANCE WITH SUCH REQUIREMENTS.
STATEFEDERAL TAXPAYER ID# BANKING INSTITUTION
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INSTRUCTIONS
This form is to be completed and filed when:
1. Applying for an established account to operate as a motor carrier
in Oregon
2. Changing the informational record on file with ODOT.
TYPE OF APPLICATION
Indicate whether new account or change in existing account.
A new carrier is a carrier that has had no previous established
account in Oregon.
A name change is when there is an existing account and only the
name has changed. The FEIN remains the same.
An ownership change is a change in entities and/or ownership
structure of a company for which there is an existing account. The
FEIN has changed.
NEW AUTHORITY/TYPE OF OPERATION
1. Your name must match exactly the name filed with your state if a
corporation or assumed business name.
2. Enter your complete mailing address and telephone number. Your
street address must also be entered if it is different than your mailing
address, or if you receive your mail through a post office box. This will
ensure UPS delivery. If your address of record with ODOT is an
agent's address, the power of attorney must specifically authorize the
use of the agent's address.
3. Indicate your type of ownership. Oregon corporations, Oregon limited
liability companies, limited liability partnerships, and businesses with
Oregon mailing addresses using assumed business names must be
registered with the Oregon Secretary of State, Corporation Division.
4. A Class B Permit authorizes a carrier to transport household goods for
hire within designated local cartage areas that are exempt from
economic regulation (see list of cities in OAR 740-060-0100).
Pursuant to ORS 825.240, the following conditions must apply: (a) the
gross revenue derived from local cartage of household goods in the
designated area by carriers cannot exceed $100,000 a year; (b) the
population of the affected city or cartage area is less than 10,000; (c)
the incorporated city or cartage area is not an essential part of a
metropolitan, industrial or homogeneous economic area; (d) the
incorporated city or cartage area is not contiguous to another city or
within the area encompassed by the commercial zone of another city;
(e) service to the public would be adversely affected; (D the carrier's
ability to render service would not be adversely affected; and (g) it is
not otherwise adverse to the public interest to exclude such area from
regulation.
5. Description of "7W" operations - Permit Authority under ORS 825.020
for operations over 26,000:
U.S. mail on a trip basis
Buses within cities and within three air miles of the city
Vehicles used in preventing or fighting forest fires
Tow trucks
Common or contract carriers transporting employees, relatives,
indigents, etc.
Florist delivery vehicles
Private carriers transporting fish
Vehicles owned by truck leasing companies used for purposes of
relocation
6. If you wish to haul commodities (except household goods) intrastate,
please complete an Application for Class 1A Permit (ODOT Form
735-9745) and include a $300 application fee.
7. List the full name, title, date of birth, and social security number of the
individual owner, each partner, each corporate officer, partners in a
limited liability partnership (LLP), or each manager/member o f the
limited liability company (LLC). If a corporation, attach a list of
shareholders, officers or directors not already listed. Attach addendum
if needed.
8. The application must be signed by the individual owner, all partners,
acorporate officer, a partner in a LLP, a manager/member of the LLC,
or Agent. Note to agent: Include your title when signing and attach a
power of attorney form.
9. Per OAR 740-040-0070 you will be required to post a Surety Bond
regardless of whether you operate on an ODOT plate, temporary
pass, or enrolled in the Oregon Weight-Mile Tax Program.
10. When operating intrastate only, you will be required to file proof of
liability insurance with ODOT. When operating interstate, review
federal regulations regarding the Minimum Levels of Financial
Responsibility for Motor Carriers.
For bond, insurance and record keeping requirements, refer to the
information available on our website.
https://www.oregon.gov/ODOT/MCT/Pages/index.aspx
CHANGE OF INFORMATIONAL RECORD
1. So that you may be accurately identified, enter your account number,
name, and current mailing address.
2. Complete the section or sections of the application form for which a
record change is requested. In the Type of Application area, identify
the change (i.e., name, ownership, address, permit, or telephone).
3. A corporate name change may require an updated corporate
certificate reflecting the change.
4. An Oregon assumed business name change requires an update with
the Oregon Secretary of State, Corporation Division.
5. If your operation has a change in ownership, a new application for
motor carrier account must be completed and submitted to ODOT.
Upon approval of the application, a new account number will be
assigned.
NOTE:
The completion of this form does not constitute authority to operate in the
state of Oregon. In addition, a Temporary Pass, OR DOT plate must be
obtained, or enrolled in the Oregon Weight-Mile Tax Program.
After your account application has been approved and you have registered
a motor vehicle with the Department (see Vehicle Registration/Amendment,
ODOT Form 735-9076), weight-mile tax report forms will be mailed to you.
ADDITIONAL INFORMATION MAY BE OBTAINED BY CALLING
(503) 378-6699.
FILE THIS ORIGINAL APPLICATION WITH THE SALEM OR PORTLAND
BRIDGE REGISTRATION OFFICE OR MAIL:
OREGON DEPARTMENT OF TRANSPORTATION
COMMERCE AND COMPLIANCE DIVISION
3930 FAIRVIEW INDUSTRIAL DRIVE SE
SALEM O REGON 97302-1166
OR
FAX TO (503) 378-6880
For downloadable forms, go to:
https://www.oregon.gov/ODOT/MCT/Pages/FormsandTables.aspx
To find out more about Oregon Trucking Online and the transactions you
can process there, go to:
https://www.oregontruckingonline.com/cf/MCAD/pubmetaentry/index.cfm.
Watch for an email from the ODOT computer Security Unit notifying you of
your PIN assignment for Trucking Online access. The PIN notification will
be sent to the email address listed on your application. An activation notice
will also be sent by U.S. mail to the official address of record for your
account.
You can now pay Trucking Online transactions using “Direct Payment”.
Direct Payment is a secure electronic payment delivery system for
Business and Individual bank accounts. The Direct Payment feature gives
carriers another payment alternative to transacting business with a credit
card or charging transactions to an CCD account.
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APPLICATION FOR MOTOR CARRIER ACCOUNT (Oregon)

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Completed 21 January 2022

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