1st Security - Application

BMC-85 Application

There are two ways to fill out the Brokers Trust Fund Questionnaire (BMC-85)

You can fill out this form
Click here to print out a form

Please select your Plan Type

Company Information

Do you now have an Operating Authority from or Application being processed by the FMCSA? Yes No

If you have Operating Authority enter Motor Carrier Number:

Legal Company Name as shown on the Form OP-1 with the FMCSA:

Doing Business As - Company Name :

Legal Address

Street:

City:

County:

State:

Zipcode:

Mailing Address

Street:

City:

County:

State:

Zipcode:

Ownership Form:

President

Vice President

Secretary

Past MC Numbers:
Have you, your company or any company officers ever been associated with past or present MC#'s? Yes No

Contact Information

Daytime Phone:

Mobile Phone:

Fax:

Email Address:

@

Personal Information

Full Name of Responsible Person:

Home Address

Street:

City:

State:

Zipcode:

Social Security Number:

Date of Birth:

Current Employment:

Phone number:

Drivers License#:

DL State:

Spouse Information

Full Name

Social Security Number:

Date of Birth:

Current Employment:

Phone number:

Drivers License#:

State:

Property Information

Property Type:

Occupancy:

Other Information

Submit secondary application for all Partners, Joint Owners, and LLC Members.

All applicants must forward a copy of Articles of Incorporation, LLC Filings, or Partnership agreements before preparation of legal documents.

I certify that the above statements are true and accurate to the best of my knowledge.

In the event of selection of any installment option, I hereby authorize a personal credit and employment history inquiry on all applicants.