ACTION TRUCK BROKERAGE PO Box 151 WEISER, ID
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1 ACTION TRUCK BROKERAGE PO Box 151 WEISER, ID Accounting/Administrative Weiser, Idaho (208) (888) FAX DISPATCH Laura-North Dakota Becky-Filer, Idaho Tracy-Boise, Idaho (701) (208) (208) (888) (877) (800) (888) FAX (888) FAX (888) FAX CARRIER INFORMATION NAME: STREET ADDRESS: WEB SITE: REMIT TO ADDRESS: LOCAL PHONE: WATTS: FAX: AUTHORITY # HAZ MAT PERMIT # TYPES OF TRAILERS: QTY: TYPE: QTY: TYPE: QTY: TYPE: QTY: # OF POWER UNITS: WHAT STATES DO YOU OPERATE IN? WHAT ARE YOUR LANE PREFERENCES: ORIGIN: ORIGIN: ORIGIN: DESTINATION: DESTINATION: DESTINATION: CONTACT INFORMATION If you have a company directory with phone extensions and/or addresses please forward. DISPATCHER(S): CELL #: CELL #: CELL #: ACCOUNTS RECEIVABLE/ BILLING CONTACT: PHONE: OR FACTORING COMPANY NAME: PLEASE FAX TO OR TO: jonna@actiontruckbrokerage.com: Carrier information sheet MC Authority Current Certificate of Insurance for cargo and liability coverage (Action Truck Brokerage must be a Cert. holder!)
2 ACTION TRUCK BROKERAGE PO Box 151 WEISER, ID Accounting/Administrative Jonna Duvall Weiser, Idaho (208) (888) FAX DISPATCH Laura-North Dakota Tracy-Boise, Idaho (701) (208) (888) (800) (888) FAX (888) FAX Becky-Filer, Idaho (208) (877) (888) FAX CREDIT REFERENCES Valley Transportation Services Arlo G. Lott Trucking St Highway 16 PO Box 110 Grand Meadow, MN Jerome, Idaho Stephanie (507) Andy (208) East River Lumber & Grain Eby Brothers PO Box 128 PO Box 9342 Mobride, SD Boise, Idaho Wayne (605) Greg (208) Gary Amoth Trucking Sherman Brothers Trucking PO Box 448 PO Box 706 Twin Falls, Idaho Eugene, Oregon Gary (208) Ann (503) BANK REFERENCE Intermountain Community Bank Weiser. Idaho Heather Wilkins (208) Active Member Internet Truckstop Diamond Broker Program SURETY BOND INFORMATION LSJ Insurance Agency Inc Palmetto Ave. Ste. 100 Winter Park, FL Lisa Parent (888)
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5 UNITED STATES OF AMERICA DEPARTMENT OF TRANSPORTATION PIPELINE AND HAZARDOUS MATERIALS SAFETY ADMINISTRATION HAZARDOUS MATERIALS CERTIFICATE OF REGISTRATION FOR REGISTRATION YEAR(S) Registrant: ACTION TRUCK BROKERAGE Attn: JOHN B. DUVALL PO BOX 151 WEISER, ID This certifies that the registrant is registered with the U.S. Department of Transportation as required by 49 CFR Part 107, Subpart G. This certificate is issued under the authority of 49 U.S.C It is unlawful to alter or falsify this document. Reg. No: V Issued: 05/21/2013 Expires: 06/30/2014 HM Company ID: Record Keeping Requirements for the Registration Program The following must be maintained at the principal place of business for a period of three years from the date of issuance of this Certificate of Registration: (1) A copy of the registration statement filed with PHMSA; and (2) This Certificate of Registration Each person subject to the registration requirement must furnish that person s Certificate of Registration (or a copy) and all other records and information pertaining to the information contained in the registration statement to an authorized representative or special agent of the U. S. Department of Transportation upon request. Each motor carrier (private or for-hire) and each vessel operator subject to the registration requirement must keep a copy of the current Certificate of Registration or another document bearing the registration number identified as the "U.S. DOT Hazmat Reg. No." in each truck and truck tractor or vessel (trailers and semi-trailers not included) used to transport hazardous materials subject to the registration requirement. The Certificate of Registration or document bearing the registration number must be made available, upon request, to enforcement personnel. For information, contact the Hazardous Materials Registration Manager, PHH-52, Pipeline and Hazardous Materials Safety Administration, U.S. Department of Transportation, 1200 New Jersey Avenue, SE, Washington, DC 20590, telephone (202)
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