UCRA

THIS IS AN ANNUAL FEE FOR BROKERS; FREIGHT FORWARDERS; AND MOTOR CARRIERS.

THIS ANNUAL FEE IS FOR "ACTIVE" MC AND FF NUMBERS

Fees vary to amount of Vehicles for motor carriers...

*I can even help you with your insurance needs.

Complete package - NO HIDDEN COSTS!
For further assistance call us at 866-382-6638

NAME *Required

DOING BUSINESS AS:

MC AND USDOT number

PHYSICAL ADDRESS, CITY, STATE & ZIP CODE

MAILING ADDRESS, CITY, STATE & ZIP CODE

If address requires new phone numbers, please show new phone numbers below.

TELEPHONE NUMBER:
* Required FAX NUMBER :

EMAIL ADDRESS:
* Required

BUSINESS TYPE:
Individual;
Partnership;
Corporation (State - );
LLC (State -

Name of Owner/Officer: * Required

Title of Owner/Officer:
If other, please specify:

Payment Method: *required

Credit Card Information

Type:

Amount Charged:

Card Number:

Expiration:

Security Code: (4 digits for AMEX; 3 digits for all other card types)

Cardholder Name:

Billing Street Address:

Billing Zip Code:

All information is strictly CONFIDENTIAL and is NOT SHARED with anyone! There is no obligation.

DO YOU HAVE THE BEST AUTHORITY FOR 2008???

DO YOU NEED AN INSURANCE QUOTE???

DO YOU KNOW HOW TO MAXIMUM YOUR AUTHORITY???

How did you hear about us?

(((NOTE: If this form does not Submit properly, please call Rex at 866-382-6638 and/or fax to 866-729-5904.)))