Instructions for Georgia Intrastate Motor Carrier …

1 DPS UCR 2 Instructions for Georgia Intrastate Motor Carrier (GIMC) Applications for GIMC must include the following required documentation: 1. Completed Georgia Intrastate Motor Carrier (GIMC) Application; and, 2. Form E: (Required by For Hire only). Issued to applicant by insurance provider. Have your insurance company (not your agent) file evidence of public liability and property damage insurance; (Note: The information on your application and Form E must concur); and, 3. Completed, signed and notarized Georgia Security and Immigration Act (GSICA) Affidavit as required by OCGA 50 36 1); and, 4. Copy of the front and back of a Secure and Verifiable Document, as required by 50 36 2; and, 5. Proof (diploma, certificate, etc.) that the applicant has completed, within the preceding 12 months, an educational seminar on Motor Carrier operations and safety regulations authorized by the Commissioner of Public Safety. 6. Payment by one of the following methods: Credit Card, Money Order, Certified Bank Check GIMC registrations are not active until ALL required documentation is received and all fees paid.

2 Applicants are encouraged to apply online at the Georgia Department of Public Safety website. However, once you have completed your online application and have paid all fees, the additional required documentation described above must be submitted by Mail to the Georgia Department of Public Safety, UCR GIMC Section, Box 1456, Atlanta, Georgia 30371 1456, OR by email to OR by Fax to 404 624 7248. If you have questions, contact: Georgia Department of Public Safety UCR GIMC Section Box 1456 Atlanta, Georgia 30371 1456 Phone: (844) 238 8097 (toll free) or (404) 624 7247 Fax: (404) 624 7248 Email: DPS UCR 2 Georgia DEPARTMENT OF PUBLIC SAFETY: Georgia Intrastate Motor Carrier (GIMC) Application To register online go to : GIMC Registration SECTION 1: GENERAL INFORMATION Registration Year: 2017 2018 USDOT Number GA GIMC MCA Number Email Address FEIN Telephone Number Fax Number Business Legal Name Doing Business Under the Following Name (DBA) Principal Place of Business (Street Address) City State Zip Code Business Mailing Address (If different from above) City State Zip Code For Corporations, Limited Liability, and where applicable, please list Officer of Business Name: Title.

3 Please lists the Vehicle Identification Numbers below or on the attached sheet VIN 1: VIN 2: VIN 3: VIN 4: Section 2: Motor Carrier Classification (Please check all that apply) 1. For-Hire 2. Private 3. Motor Carrier Transporting Hazardous Materials 4. Bus/Motorcoach 5. Wrecker/Towing Company 6. Household Goods 7. Broker 8. Leasing Company 9. Freight Forwarder Please Include All Motor Vehicles That Travel EXCLUSIVELY in Intrastate Commerce (GA Only) Total Number of Motor Vehicles _____ Multiply (X) Per Vehicle Total Fees Due = $_____ x $ before January 1st, or if New Applicantx $ after January 1st The above described applicant hereby applies for the registration of Intrastate UCR of the vehicle or vehicles which it operates within the border of Georgia ( Intrastate ) during the period for which such registration is effective. The operation of such vehicle or vehicles shall be in accordance with 40-2-140.

4 I the undersigned, under penalty for false statement, certify that the above information and vehicle count is true and correct and that I am authorized to execute and file this document on behalf of the applicant (Print) Name of Owner or Authorized Representative Date Signature Title Georgia Department of Public Safety UCR-GIMC Section Box 1456 Atlanta, Georgia 30371-1456 Phone: (844) 238-8097 (toll-free) or (404) 624-7247 Fax: (404) 624-7248 E-mail: Note: GIMC registrations are not active until ALL required documentation received and all fees paid in full. DPS UCR 2 Please lists the additional Vehicle Identification Numbers below VIN 5: VIN 6: VIN 7: VIN 8: VIN 9: VIN 10: VIN 11: VIN 12: VIN 13: VIN 14: VIN 15: VIN 16: VIN 17: VIN 18: VIN 19: VIN 20: VIN 21: VIN 22: VIN 23: VIN 24: VIN 25: VIN 26: VIN 27: VIN 28: VIN 29: VIN 30: VIN 31: VIN 32: VIN 33: VIN 34: VIN 35: VIN 36: VIN 37: VIN 38: VIN 39: VIN 40: VIN 41: VIN 42: VIN 43: VIN 44: VIN 45: VIN 46: VIN 47: VIN 48: VIN 49: VIN 50: VIN 51: VIN 52: VIN 53: VIN 54: VIN 55: VIN 56: VIN 57: VIN 58: VIN 59: VIN 60: VIN 61: VIN 62: VIN 63: VIN 64: VIN 65: VIN 66: VIN 67: VIN 68: VIN 69: VIN 70: VIN 71: VIN 72: VIN 73: VIN 74: VIN 75: VIN 76: VIN 77: VIN 78: VIN 79: VIN 80: VIN 81: VIN 82: VIN 83: VIN 84: VIN 85: VIN 86: VIN 87: VIN 88: VIN 89: VIN 90: VIN 91: VIN 92: VIN 93: VIN 94: VIN 95: VIN 96: VIN 97: VIN 98: VIN 99: VIN 100.