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

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

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

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

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

{{ ['First Time (initial registration) - $150.00','Renewal of Registration - $125.00'][$index] }}

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

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

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

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

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

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

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

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

{ binding displayValue, mode=oneTime }

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

{{ ['Yes, I will enter it below','No, please verify my NAICS code - $25.00'][$index] }}

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 }

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

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

{ binding displayValue, mode=oneTime }

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

{ binding displayValue, mode=oneTime }

CONFIRMATION AND PAYMENT

Processing and Application Fee Due Now {{ 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

(1 year) = $275
(2 years) = $525
(3 years) = $775

Not Small Business:
includes the $25 DOT processing fee

(1 year) = $2,600
(2 years) = $5,175
(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.

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

{ binding displayValue, mode=oneTime }

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

{ binding displayValue, mode=oneTime }

Pay by Credit Card

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

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

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

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

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

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

Pay by Bank Account

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

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

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

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

Expedite the processing

Expedite Hazmat Certificate Processing - $47.50 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

It is highly recommended to expedite the processing in order to obtain the HM Certificate by June 30th.

Laminated Certificates

Add Mailed Laminated Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

From production mailed copy is received within 7-10 business days.

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

LEAVE BLANK. FOR INTERNAL USE ONLY.

Important:
If you selected to Pay by Credit Card for Hazmat Certificate Endorsement, you must select check box below the credit card information below.

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

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

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

{binding BillingName}

{binding BillingAddress.FullInternationalAddress}

{binding PhoneNumber}

{binding EmailAddress}

{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}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

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

{binding displayValue}

Physical Address (if different than mailing) {{ 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}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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

{binding displayValue}

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 }

Select all categories that best describe your operations: {{ 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}

CONFIRMATION AND PAYMENT

Processing and Application Fee Due Now {{ 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

(1 year) = $275
(2 years) = $525
(3 years) = $775

Not Small Business:
includes the $25 DOT processing fee

(1 year) = $2,600
(2 years) = $5,175
(3 years) = $7,750

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

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

{binding displayValue}

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}

Expedite the processing

Expedite Hazmat Certificate Processing - $47.50 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

It is highly recommended to expedite the processing in order to obtain the HM Certificate by June 30th.

Laminated Certificates

Add Mailed Laminated Certificate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

From production mailed copy is received within 7-10 business days.

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

{binding displayValue}

Important:
If you selected to Pay by Credit Card for Hazmat Certificate Endorsement, you must select check box below the credit card information below.

CONFIRMATION AND PAYMENT

Pay by Credit Card

Pay by Bank Account

Expedite the processing

Laminated Certificates

{~ Payment_Block_Label}

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

{{ Cognito.resources['order-billing-info-header'] }}

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

{{ Cognito.resources['order-billing-info-header'] }}

CONFIRMATION AND PAYMENT

Pay by Credit Card

Pay by Bank Account

Expedite the processing

Laminated Certificates