{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{binding Name}:	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

1: COMPANY INFORMATION

Name of Person Completing this Order {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What is your role in the company? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DBA (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

U.S. DOT Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

MC/MX Number (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Select below to provide FEIN or Social Security Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Federal Tax ID Number (FEIN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security Number (SSN) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Physical Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is your physical company address the same as your mailing address? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address (if different than physicall address) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2. VEHICLE INFORMATION

Vehicle Types

Vehicle Type {binding ItemNumber}

Ownership Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Number of this type of vehicles in your fleet? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Maximum number of passengers: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

What type of "other" vehicle? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If you have more vehicles of other type click the ADD VEHICLE TYPE button to add more vehicles

3: TRAILER INFORMATION

If you do not operate any trailers please indicate "0".
Do not leave this field blank.

Number of Trailers {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Ownership Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Are any of the trailers Hazmat Cargo Trailers? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Enter the number of Hazmat Cargo Trailers: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

4: DRIVER INFORMATION

Total number of drivers: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

From the Total, how many have a CDL license? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you drive over the 100-mile radius? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

5: OPERATION TYPE

ESTIMATED MILEAGE IN 2019

Total miles travelled in 2020 (Estimated between January - December) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Estimated miles traveled in previous year (2019): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Note, you can estimate this number. (permitted margin of error: nearest 10,000 miles).Insert and format text, links, and images here.

Cargo Carried {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Operation Classification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

INTERSTATE VS INTRASTATE

Do you stay within your base state or conduct business across multiple states? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

You are deemed an INTERSTATE carrier if:
1) your vehicle crosses state lines; and/or,
2) your cargo originates from out of state or is transported out of state
(*see the bill of lading for destination/origin of cargo)

Special notes / additional information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

SELECT ALL APPLICABLE OPTIONS TO YOUR COMPANY:

The following questions pertain to the 2019-2020 period:

Select all categories that best describe your operations in 2019-2020: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

In which states did you transport the above HazMat material(s)? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hazardous Materials (Carrier or Shipper) - CHECK ALL THAT APPLY

Div. 1.1 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 1.2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 1.3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 1.4 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 1.5 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 1.6 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.1 (Flam. Gas) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.1 LPG {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.1 (Methane) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.3A {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.3B {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.3C {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 2.3D {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

COMB LIQ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 4.1 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 4.2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 4.3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 5.1 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div.5.2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 6.1A {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 6.1B {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 6.1 POISON {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 6.1 SOLID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Div. 6.2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 7 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

HRCQ {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 8 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 8A {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 8B {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CLASS 9 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ELEVATED TEMP. MATERIAL {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

INFECTIOUS WASTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

MARINE POLUTANTS {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

HAZARDOUS SUB (RQ) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

HAZARDOUS WASTE {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ORM {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ENTER HAZMAT CODE / UN:

HazMat Code/UN: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Transporting hazardous materials requires a certificate of registration in addition to the hazardous materials permit. If you did not have a certificate of registration for this year please check the box below to obtain one.

Please note that unlike the hazmat permits, certificate of registration must be renewed every year. Whereas, hazmat permit updates must be filed every two years.

Yes, I'd like to obtain the Certificate of Registration {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please note that unlike the hazmat permits, certificate of registration must be renewed every year. Whereas, hazmat permit updates must be filed every two years.

HAZMAT CERTIFICATE OF REGISTRATION

How do you transport HazMat cargo? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Railroad Alphabetic Code (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Do you know your NAICS code? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

The North American Industry Classification System (NAICS) Code for Primariy Business Activity is a 6-digit code. It is required to file the HazMat Registration Statement. If you do not know your code it can be verified for you with the NAICS for an additional charge.

NAICS code (Business Category - 6 digits) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

NAICS verification: Describe your type of business (cargo, operations): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Type Of Registration {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Select Registration Period {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Certificate of Registration Processing Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

HazMat Registration Due Upon Processing by the U.S. DOT:

Small Business / Non Profit:
includes the $25 DOT processing fee

2020-2021 (1 year) = $275
2020-2022 (2 years) = $525
2020-2023 (3 years) = $725

Not Small Business:
includes the $25 DOT processing fee

2020-2021 (1 year) = $2,600
2020-2022 (2 years) = $5,175
2020-2023 (3 years) = $7,750

Am I 'Small Business' or 'Not Small Business' ?

The NAICS code (above) determines your business type. Your application will be filed if your NAICS code is Small Business. If it is determined that your business is Not Small Business, you WILL BE CONTACTED prior to filing you application. All filing fees over $1,000 will result in an agent contacting your company to confirm your application prior to processing this application with the U.S. DOT.

How would you like to pay the HazMat Registration Fee? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pay by Credit Card

Name on Credit Card {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Credit Card Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expiration Month {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expiration Year {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

CVC code (back of credit card) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Billing Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pay by Bank Account

Name of Bank Account Owner {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Routing Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Account Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Verify Account Number: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

For Hazmat Permit Renewals it is highly recommended to provide and to sign your application with your U.S. DOT PIN, in order to safeguard against errors and to file your application in timely fashion.

If you do not know your U.S. DOT PIN, please call 1-240-54-0881 and an agent will be able to assist you in resetting it.

How would you like to sign the application?

How would you like to sign the application? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

PIN NUMBER SIGNATURE

DOT PIN Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

U.S. DOT PIN Number.

You have selected to sign the Biennial Update application using your U.S. DOT PIN number. If you do not know your PIN number or if your PIN number is incorrect, please select a different signing option from the drop down menu.

Please note that the DOT PIN number is 8 characters long and it comes in the following format: number-letter-number-number-letter-letter-number-letter.

Example: 1L34UX3P

E-SIGNATURE

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

SEND A SIGNATURE BY EMAIL OR TEXT

INSTRUCTIONS:

1. Sign your name on a white piece of paper using a black pen or black marker

2. Write your DOT number below or next to your signature

3. Scan the signature or take a picture of it with your phone

4a. Email the signature to signature@hoffenmer.com

4b. Text/SMS the signature to (202) 856-6065
Note: this number can only receive text messages. To speak with an agent please call (240) 544-0881

How will you send your signature? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

REQUEST A FORM TO SIGN

You have selected to sign a manual form.

When you submit this application it will be processed by an agent assigned to your case. The processed application will be emailed to you requesting a signature. Please sign that application and return it to your agent by email or fax (return instructions will be provided in an email from your agent). Please continue to submit this application (below).

Note: manual form submission carries an extra charge due to further processing that is not required when using a DOT PIN number.

8: PAYMENT AND SUBMISSION

Processing, Filing and Confirmation Fees

Hazmat Permit Registration Filing Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Confirmation Request {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Confirmation by email: an emailing stating that your filing has been accepted by the U.S. DOT

Snapshot of your company in the U.S. DOT Database (displays your last filing and company standing; may be used as proof of filing)

Certificate of Filing is a printed document with an confirmation ID number, your filing date and an expiration date indicating your next filing. It also includes a snapshot of your company from the DOT Database. Certificate ID cards are optional (not required) and can be carried in your vehicle(s) as proof of filing. The certificate comes with an insurance against roadside violations (all roadside violations issued to your company per FMCSR 390.201 or FMCSR 390.19 will be challenged at no charge to you until the expiration of the certificate).

How many ID Cards would you like to request ($8) ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ID Cards Total: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Processing Option {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expedited processing is recommended if you need your application to be processed within 24 hours (and most times within the same business day). Situations that require expedited filings include: suspsended DOT numbers, insurance renewals, or last-minute filings. Note: a filing may be delayed if your application is missing required information. In such case, an agent will contact you within 24 hours.

Terms and Conditions

By accepting these Terms and Conditions you agree to the following general terms and conditions:

- All information herein enclosed is accurate and reflects the current status of your company, to the best of your knowledge

- The Processor (Hoffenmer Federal Applications Processor) will not be held responsible for any erroneous information provided in the herein form. All data will be submitted to the U.S. Department of Transportation as is provided in this application. The Processor will, to the best of its abilities, attempt to catch any inconsistencies and/or erronously appearing information and contact you to verify its validity

REFUNDS

- All application submissions are final and once processed refunds will not be issued. Refunds will be accepted if requested within 48 hours of filing AND if an application has not yet been processed/submitted with the U.S. DOT/FMCSA.

For the full T&C and Privacy Policy visit: https://www.hoffenmer.com/terms_conditions.html

I AGREE TO THE TERMS AND CONDITIONS {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

SIGNATURE (TYPE YOUR NAME) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

1: COMPANY INFORMATION

2. VEHICLE INFORMATION

Vehicle Types

Vehicle Type {binding ItemNumber}

If you have more vehicles of other type click the ADD VEHICLE TYPE button to add more vehicles

3: TRAILER INFORMATION

4: DRIVER INFORMATION

5: OPERATION TYPE

ESTIMATED MILEAGE IN 2019

INTERSTATE VS INTRASTATE

SELECT ALL APPLICABLE OPTIONS TO YOUR COMPANY:

Hazardous Materials (Carrier or Shipper) - CHECK ALL THAT APPLY

ENTER HAZMAT CODE / UN:

Transporting hazardous materials requires a certificate of registration in addition to the hazardous materials permit. If you did not have a certificate of registration for this year please check the box below to obtain one.

Please note that unlike the hazmat permits, certificate of registration must be renewed every year. Whereas, hazmat permit updates must be filed every two years.

HAZMAT CERTIFICATE OF REGISTRATION

Pay by Credit Card

Pay by Bank Account

How would you like to sign the application?

PIN NUMBER SIGNATURE

U.S. DOT PIN Number.

E-SIGNATURE

SEND A SIGNATURE BY EMAIL OR TEXT

REQUEST A FORM TO SIGN

You have selected to sign a manual form.

8: PAYMENT AND SUBMISSION

Processing, Filing and Confirmation Fees

Terms and Conditions

{~ Payment_Block_Label}

{{ Cognito.resources['order-transaction-details-header'] }}

{{ Cognito.resources['order-transaction-details-header'] }}

1: COMPANY INFORMATION

2. VEHICLE INFORMATION

Vehicle Types

Vehicle Type {binding ItemNumber}

If you have more vehicles of other type click the ADD VEHICLE TYPE button to add more vehicles

3: TRAILER INFORMATION

4: DRIVER INFORMATION

5: OPERATION TYPE

ESTIMATED MILEAGE IN 2019

INTERSTATE VS INTRASTATE

SELECT ALL APPLICABLE OPTIONS TO YOUR COMPANY:

Hazardous Materials (Carrier or Shipper) - CHECK ALL THAT APPLY

ENTER HAZMAT CODE / UN:

Transporting hazardous materials requires a certificate of registration in addition to the hazardous materials permit. If you did not have a certificate of registration for this year please check the box below to obtain one.

Please note that unlike the hazmat permits, certificate of registration must be renewed every year. Whereas, hazmat permit updates must be filed every two years.

HAZMAT CERTIFICATE OF REGISTRATION

Pay by Credit Card

Pay by Bank Account

How would you like to sign the application?

PIN NUMBER SIGNATURE

U.S. DOT PIN Number.

E-SIGNATURE

SEND A SIGNATURE BY EMAIL OR TEXT

REQUEST A FORM TO SIGN

You have selected to sign a manual form.

8: PAYMENT AND SUBMISSION

Processing, Filing and Confirmation Fees

Terms and Conditions