license new drugtest

THIS SECTION IS FOR PARTIES WHO ARE "LICENSED
TRANSPORTATION BUSINESS OPERATORS" SEEKING TO.......

CHANGE

DRUG-TEST CONSULTANT

OPERATOR (LICENSE HOLDER) INFORMATION:

P/S COMPLETE FORM BELOW
PS/The information you provide below is needed to complete your TCP Application.

CalPUC/PSG #:

(TCP or PSC or MTR)

COMPANY NAME:

(The "Legal Name" of your business)

FICTITIOUS NAME:

dba

(this is a non-legal name used to sell your services)

BUSINESS TAX ID#:

DRIVER LICENSE:

(owner-operator's driver license)

BUSINESS CONTACT:

(Must be an officer)

TITLE:

(must be Owner, President, CEO)

E-MAIL ADDRESS:

PHYSICAL LOCATION OF BUSINESS (WHERE RECORDS ARE KEPT)

BUSINESS ADDRESS:

SUITE/UNIT #:

CITY:

COUNTY:

STATE:

ZIP CODE:

BUSINESS PHONE:

Area-code: Phone #:

TERMINAL ADDRESS IS WHERE YOU KEEP THE VEHICLE LOCATION:

TERMINAL ADDRESS:

CITY:

COUNTY:

STATE:

ZIP CODE:

TERMINAL PHONE:

Area-code: Phone #:

COMMERCIAL INSURANCE AGENT INFORMATION:

REF: PUC GENERAL ORDER 157-D Part 5.01/ WHO MAY DRIVE FOR YOU...
ITEM	DESCRIPTION	REMARK
1.	EMPLOYEE DRIVER
2.	OWNER / OFFICERS / MANAGERS
3.	EMPLOYEE OF SUB-CONTRACTOR

You must have a Drug-Test Agent at the time of the Application. We may find you a Drug-Test Consultant, if you have not already found one.

CONTACT:

TITLE:

Company Name:

STE#:

Address:

CITY:

STATE:

ZIP CODE:

TELEPHONE:

FAX:

E-mail:

OUR FEES AND CHARGES: Please Pay...
ITEM	DESCRIPTION	FEES
	Our consulting fees for changing commercial insurance agent/broker. (Pay to .......)	$ 50
We are unable to accept payment by credit/debit cards at the present.
PLEASE, CALL US TO PAY BY CHECK AT: 323-378-6494....

MISCELLANEOUS INFORMATION:
(Use box below for any more information to add)