PUC Transportation Applications

Employee Information

See Insurance Requirements and Workers Compensation Coverage for required insurance

Does this applicant have employees?

Yes No

If you have questions concerning coverage requirements, consult the Workers’ Compensation Act of Colorado at Title 8, Articles 40-47, CRS or contact the Colorado Department of Labor and Employment, Division of Workers’ Compensation at (303) 318-8700.

Additional Information

For all Business Structures include the name and title of each Owner/Member/Partner or Director/Officer. Towing carriers must include the date of birth and driver's license number of the individual.

First

Middle

Last

Title

Birth date

License No

License State

Remove

* * * * * *

Designated Agent (DA)

For service of PUC notices, orders, and process. If the DA is an individual, he/she must be at least 18 years old and reside in Colorado.
See instructions for required documentation.

Agent Name

Address

City

State

Zip

Type of Motor Carrier Operation

Business Type

Route Type

Safety History
A permit will not be issued to an applicant with an unsatisfactory safety rating.

Last FMCSA Compliance Review Date

Current FMCSA Safety Rating

Commodities Transported
See instructions for insurance requirements.

Commodities Transported

Additional Hazmat Details

Will any vehicles have a GVWR of 10,000 pounds or more?

Yes No

Will any vehicles be transporting hazardous substances in cargo tanks, portable tanks, or hopper-type vehicles with capacities in excess of 3,500 water gallons?

Yes No

Statement and Attestation

Either the applicant or an authorized agent must electronically sign this form.

An unsigned form will not be processed.

Name

Title

Date

Confirm:

By checking this box, I acknowledge that I am the applicant (or authorized to file for the applicant) and that I have read and agree to the terms of this application. *

Authorized Signature

Affidavit of Eligibility - Sole Proprietors Only

Lawful Presence
Colorado law requires that only persons lawfully present in the United States (US) be issued a license, certificate, registration or permit. If you are a sole proprietor, you must complete the affidavit below. When requested, you must produce the valid identification.

Section A: LAWFUL PRESENCE in the United States.

I, (please print your full name)

First

Middle

Last

swear or affirm under penalty of perjury under the laws of the State of Colorado that:

I am a US citizen.
I am not a US citizen and I am lawfully present in the US pursuant to federal law.

Identification

All areas in this section must be completed.

Section B: Type of Identification

Select your identification type:

Enter the name of the state or the federal agency name where this was issued:

Enter the identification number:

Enter the expiration date:

Attestation

Section C: Attestation.

Authorized Signature

Date

Documentation

Additional documentation is required for your application. Certificates must be obtained from the Colorado Secretary of State and attached to this application.

Business Structure Document:

Trade Name Document Type:

UCR Payment Verification:

Foreign Entity Authority:

Vehicle Inspection Report:

Application Fee:	$
Stamp Fee:	$
Total:	$

The following errors were found on your application. An asterisk (*) has been placed next to each error.

Affidavit of Eligibility - Sole Proprietors Only