Environmental Protection and Growth Management Department ENVIRONMENTAL AND CONSUMER PROTECTION DIVISION 1 North University Drive, Box #302 • Plantation, Florida 33324 • 954-765-4400 • broward.org/consumer

Certified Motor Carrier (CMC)

License Application Information and Instructions

Supporting Documents You must attach the following supporting documentation to your application:

A copy of your current vehicle registration A copy of your certificate of insurance compliant with Florida law A copy of current corporate/partnership/fictitious name documents

Note: certificates of insurance must prove adequate insurance coverage and be in full force and

effect. The certificates must list the Broward County Environmental and Consumer Protection

Division as a certificate holder and must provide at least 30 days advance notice ofcancellation. Certificate of auto liability insurance must indicate minimum limits of $125,000/$250,000/$50,000. For each vehicle, submit a certificate with the year, make and Vehicle Identification Number (VIN); for a fleet of vehicles, provide a schedule listing the vehicles with year, make and VIN.

Initial Application Fee

$2,000 per Broward County Administrative Code Sec 40.37

Annually Recurring Fee Up to 10 vehicles ........................................................................................ $200 per vehicle Up to 25 vehicles ........................................................................................ $180 per vehicle Up to 50 vehicles ........................................................................................ $170 per vehicle Up to 100 vehicles ...................................................................................... $160 per vehicle Up to 250 vehicles ...................................................................................... $140 per vehicle Up to 500 vehicles ...................................................................................... $120 per vehicle Up to 1,000 vehicles ................................................................................... $100 per vehicle Up to 2,000 vehicles ................................................................................... $80 per vehicle Up to 5,000 vehicles ................................................................................... $60 per vehicle

Payment Methods

Business Check Make checks payable to: Broward County Board of County Commissioners

Credit Card Complete a credit card authorization form.

If you plan to pick up from Port Everglades, you must apply for a Port Everglades Business Permit. All permits expire June 30th. Each vehicle must be inspected and proof of insurance provided by June 30th to be permitted to operate during the following year.

Return this application with all necessary documentation and payments to the address above.

Revised 3/2017 2

Environmental Protection and Growth Management Department ENVIRONMENTAL AND CONSUMER PROTECTION DIVISION 1 North University Drive, Box #302 • Plantation, Florida 33324 • 954-765-4400 • broward.org/consumer

Application for a Certified Motor Carrier (CMC) License

New Application Renewal Application Permit Year

Criminal Background Check Notice All business owners, partners, directors, officers and shareholders owning, holding, controlling or having a beneficial interest in 25% or more of the issued and outstanding stock of a corporate general partner of a partnership will be subject to a criminal background check as part of this application.

Business Information

Individual

Partnership

Corporation

Business Name Legal Entity Formation Date

Business Account CMC#

DBA Name (if different)

Business Owner Name

Business Owner Name (if individual)

Business Owner Date of Birth (if individual)

Business Owner Residential Address (if individual) City State Zip

Business Address

City

State

Zip

Business Mailing Address

City State Zip

Business Phone Business Mobile Phone Business Fax

Please list any and all trade names the applicant operates, intends to operate and has previously operated under. Use “N/A” if not applicable:

Business Website

Business Email

Attach documentation which demonstrates that all corporate or partnershipapplicants are qualified to do business under the laws of Florida.

Revised 3/2017 3

Business Owner, Partner, Director, Officer, Registered Agent & Shareholder Information Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Owner General Partner Limited Partner Director Officer Registered Agent Stockholder (25% interest or more) Name Federal ID # or Driver License #

Address Date of Birth

Yes No HAVE ANY OF THE AFOREMENTIONED APPLICANTS:

Been adjudicated guilty or of which adjudication has been withheld of a crime within the last 5 years of the date of application?

Been adjudicated guilty or of which adjudication has been withheld of any crime relating to motor vehicles?

Been adjudicated guilty of a crime or of which adjudication has been withheld that bears a substantial relationship to the application for a CMC license?

Been previously denied a permit, certificate or lost a license by the Division due to suspension, abandonment or forfeiture?

Failed to satisfy any civil fines, penalties or fees arising out of an administrative or enforcement action pursuant to Chapter 22½ of the Broward County Code of Ordinances?

If you answered yes to any of these questions, please include a summary on a separate sheet. Use a separate sheet to list additional owners, partners, directors, officers or shareholders if the space provided in this application is not sufficient.

Revised 3/2017 4

Vehicle Information

Please provide a description of all vehicles to be certified under the CMC license as required by Section 22½-9C. Provide

additional sheet(s) as necessary in order to list all vehicles.

Certificate No. Vehicle Year Make/Model Passenger

Capacity Vehicle Identification No. (VIN) Proof of Insurance Provided

TOTAL VEHICLES:

Revised 3/2017 5

Applicant’s Signature

I certify, under penalty of law that the information provided on this application is true and correct. I further certify that I will abide by the provisions of Chapter 22½ of the Broward County Code of Ordinances and the laws of the State of Florida and all applicable requirements of the Americans with Disabilities Act (ADA) of 1990, as amended. I certify that all certified motor carrier drivers that will operate under this license will undergo a background check and meet the requirements of Section 22 ½ 8(e), and that all certified motor carrier vehicles operating under this license will be inspected and meet the requirements of Chapter 22½ of the Broward County Code of Ordinances.

Authorized Signature (President or Vice President if corporation; General Partner if partnership)

Date

Name

Title

Corporate Attestation

I hereby attest the signature above is true and correct.

Subscribed on

at

,

,

Date City County

State of . State

(CORPORATE SEAL)

Corporate Secretary Signature

Date

NOTARY PUBLIC STATE OF ________________

COUNTY OF _______________

Sworn to (or affirmed) and subscribed before me this day of ,

20 , by

(NOTARY SEAL)

Signature of Notary Public – State of Florida

Name of Notary Typed, Printed or Stamped

Personally Known or Produced Identification

Type of Identification Produced