Fill and Sign the Fillable Online Sample Donation Letter for Non Profit Form

State of Alaska Commercial Vehicle Enforcement 11900 Industry Way M2 Anchorage AK 99515 PH 1 (907) 365-1210 UNIFIED CARRIER REGISTRATION FORM FX 1 (907) 365-1220 Year 2011 Register online at http://www.ucr.in.gov/ SECTION 1. GENERAL INFORMATION USDOT Number MC or MX Number FF Number Telephone Number Legal Name Fax Number E-Mail Address Doing Business Under The Following Name (DBA) Principal Place Of Business Street Address (See Instructions) Principal Business City Principal Business State Zip Code Mailing State Mailing Zip Code Mailing Street Address Mailing City SECTION 2. CLASSIFICATION – Check All That Apply Motor Carrier Motor Private Carrier Broker Leasing Company SECTION 3. FEES DUE-BROKERS, FREIGHT FORWARDERS AND LEASING COMPANIES ONLY Freight Forwarder Note: If your company is also a motor carrier or motor private carrier, skip this section and go to section 4. Brokers, freight forwarders and leasing companies (not combined with a motor carrier entity), please submit the amount due of $76 in the form of payment acceptable by your base state and go to Section 7. SECTION 4. NO. OF MOTOR VEHICLES– MOTOR CARRIER & MOTOR PRIVATE CARRIER Check only one box: The number of vehicles shown below has been taken from section 26 of your last reported MCS-150 form. The number of vehicles shown below is the total number owned and operated for the 12-month period ending June 30, 2010. LINE NO. NUMBER OF STRAIGHT TRUCKS AND TRACTORS (COLUMN A) (COLUMN B) NUMBER OF MOTOR COACHES, SCHOOL BUSES, MINI-BUSES, VANS AND LIMOUSINES (COLUMN C) TOTAL (COLUMN D) 1. Subtract:  The number of vehicles on Line 1 in Column C above that has a vehicle capacity of 10 or less passengers, including the driver. 2.  (Optional) The number of vehicles on Line 1 in Column A above that is used only in intrastate ( ) commerce. (Optional) Add a number of vehicles not shown on Line 1 above that are:  Commercial motor vehicles operating solely in intrastate commerce. (See instructions for definition of commercial motor vehicle.) 3.  Used in commerce to transport passengers or property for compensation and have a GVWR or GVW of 10,000 lbs or less, or a passenger capacity of 10 or less, including the driver. 4. Total Number of Vehicles (Line 1 minus Line 2 plus Line 3) SECTION 5. FEE TABLE Number of Number of Vehicles Amount Due Number of Vehicles Amount Due Amount Due Vehicles $76 $452 0-2 6-20 101-1000 $7,511 3-5 $227 21-100 $1,576 1001 or more $73,346 SECTION 6. FEES DUE – MOTOR CARRIER & MOTOR PRIVATE CARRIER Using the number of vehicles in Section 4, Line 4 above, enter the Amount Due from the table above. Note: See last page of this pamphlet for the types of payment your selected base state will accept. $ SECTION 7. CERTIFICATION I, the undersigned, under penalty for false statement, certify that the above information is true and correct and that I am authorized to execute and file this document on behalf of the applicant. (Penalty provisions subject to the laws of the registration state.) Date Name Of Owner Or Authorized Representative (Printed) Signature Title