1: COMPANY INFORMATION

 

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

 

 

 

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Numbers only

{ binding firstError.message }

Optional

 

 

COMPLIANCE PROGRAM COST (ANNUAL) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

{ binding firstError.message }

1-9999

{ binding firstError.message }

 

 

SAFETY COMPLIANCE PROGRAM

This program enrolls your company in an annual compliance screening. Your company will be notified about all federal (FMCSA, DOT and IRS) mandates that pertain specifically to your company.

Your CSA Safety Scores will be monitored and you will be alerted quarterly about significant changes and how/which drivers contribute to your compliance rating.

You will receive monthly alerts if you are in danger of being audited by the U.S. DOT (DOT Compliance Review) or if your ISS scores change to 75 or higher. (ISS scores determine whether or not your vehicles will be inspected at weight stations). 

 

 

 

Terms and Conditions

 

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

 

GENERAL

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

- Hoffenmer 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. Hoffenmer 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.

 

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

Use your mouse or open this application on your phone and sign with your finger

{ binding firstError.message }

 

 

{ binding firstError.message }

If an agent has assisted you in filing this application please provide their code here. If no one assisted you with this application or you do not know your agent’s code please leave this field blank.

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}{binding displayValue}
{binding Name}:{binding displayValue}---
{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

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

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

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

{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}

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

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

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

{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}

1: COMPANY INFORMATION

 

Name of Person Completing this Order {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Position in company? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

 

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DBA (if applicable) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
DOT Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Enter your US DOT Pin Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

COMPLIANCE PROGRAM COST (ANNUAL) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

Enter the number of drivers to enroll: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Total for Drivers: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

 

 

SAFETY COMPLIANCE PROGRAM

This program enrolls your company in an annual compliance screening. Your company will be notified about all federal (FMCSA, DOT and IRS) mandates that pertain specifically to your company.

Your CSA Safety Scores will be monitored and you will be alerted quarterly about significant changes and how/which drivers contribute to your compliance rating.

You will receive monthly alerts if you are in danger of being audited by the U.S. DOT (DOT Compliance Review) or if your ISS scores change to 75 or higher. (ISS scores determine whether or not your vehicles will be inspected at weight stations). 

 

 

 

Terms and Conditions

 

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

 

GENERAL

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

- Hoffenmer 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. Hoffenmer 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.

 

I AGREE TO THE TERMS AND CONDITIONS {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Today's Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
SIGNATURE (TYPE YOUR NAME) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

 

 

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