Motor Carrier Membership Request

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Company Name	*
Mailing Address	*
City	*
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Zip	*

Physical Address	*
City	*
State	*
Zip	*

Company Website

Number of drivers based in Idaho	*
Number of drivers with HazMat Endorsements	*

Most Recent 12 Months Idaho Miles Driven	*
Do you operate Longer Combination Vehicle’s (LCV) Yes No
Check one conference that most closely fits your company Highway Carrier: Truckload, LTL, for-hire, private, package carriers, owner operators and lessors. Resource Transporter: Unprocessed agriculture, logs, chips, cattle and mining. Specialized Transport Services: Household goods, warehousing, intermodal, regional distributor and specialized equipment.
Type of Product or Service	*
Primary Contact	*
Primary Contact Title	*
Primary Contact Office Phone	*
Primary Contact Cell Phone	*

Legislative District
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Additional Key Staff

Terminal Managers Name	*
Terminal Managers Location	*

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