Must be completed by an Officer or Authorized Company Representative. Carrier Region NortheastMidwestSoutheastSouth CentralGreat PlainsWest Coast Northeast: Maine, Vermont, New Hampshire, Rhode Island, Massachusetts, Connecticut, New York, New Jersey, Delaware, Maryland, Virginia, Pennsylvania (East of Altoona, PA), Quebec, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island Midwest: Michigan, Ohio, Indiana, Illinois, Kentucky, West Virginia, Pennsylvania (West of Altoona, PA), Ontario Southeast: Tennessee, North Carolina, South Carolina, Georgia, Florida South Central: Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama Great Plains: Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas, New Mexico, Colorado, Utah, Wyoming, Idaho, Montana West Coast: Washington, Oregon, California, Nevada, Arizona, British Columbia, Alberta, Saskatchewan, Manitoba, Yukon, Northwest Territories, Nunavut Carrier Name Trade D/B/A Names Contact Name Dispatchers Phone (Toll-Free) # Phone (Local) # Phone (After-Hours) # Fax # Document Fax # Remit to or Factoring Company Contact Name Remit to Phone # Billing Fax # Safety Contact State of Incorporation or Organization MC # DOT # Federal EIN # FMCSA Rating SatisfactoryConditionalUnsatisfactoryNot Rated If FMCSA rating is Conditional, Not Rated, or recently changed, please explain: Max Net Cargo Weight (lbs) Provide advances (ComChecks) to drivers/office for operating expenses (fuel, tolls)? YesNo Provide advances (ComChecks) to your drivers for Lumper fees? YesNo Vans # Reefer # Flatbead # Bonded? YesNo HazMat Certified? YesNo SmartWay Certified? YesNo Canada? YesNo Mexico? YesNo Intrastate? YesNo Warehousing? YesNo EDI Tracking? YesNo Drop Pools? YesNo Name Title Email By checking this box, I hereby digitally sign for and verify that all information provided in this Carrier Profile is complete and accurate to the best of my knowledge and belief.