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ICC AUTHORITY TEMPS US DOT PERMIT SERVICES HAZ MAT UCR CONTACT US

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DISMISSED AUTHORITY APPLICATION

Note: Not all applications can be reactivated. There is no fee to determine if your application can be re activated. Upon submission of this information we will check to see if your application qualifies. If your application can be reactivated we can provide this service for $75. You will not be charged until you agree to have us reinstate your application.

Email Address:
Fill out this section EXACTLY as it appears on your company auto liability insurance policy.
Legal Name
DBA(if any)
Federal ID Number:
Docket Number:	MC-
Business Address
Street:
City:
State:
Country:
Zip:
Mailing Address
Street:
City:
State:
Country:
Zip:
Phone:
Fax:
Liability Insurance Agent's Name And Telephone:
Cargo Insurance Agent's Name And Telephone:
Type Of Authority Applied For:	Common Contract Broker Freight Forwarder