MCMIS MOTOR CARRIER SAFETY PROFILE ORDER FORM

Follow the instructions on pages 17-18 of the "Catalog of MCMIS Reports" to properly complete this form

A.

SPECIFY CARRIER INFORMATION

Please provide the following information for each carrier.

[If ordering more than one profile, provide information for the additional carriers on a separate sheet of paper.]

Specify Carrier Name:

Carrier Street Address:

Carrier City:

State:

Zip Code:

Carrier USDOT Number:

Carrier MC/ICC Number:

B.

PROVIDE YOUR MAILING ADDRESS

CONTACT NAME:

COMPANY NAME:

STREET:

CITY:

STATE:

ZIP CODE:

TELEPHONE   NUMBER:

DATE:

C.

CALCULATE COST

COST OF CARRIER SAFETY PROFILE:  $27.50  (This is a non-refundable processing charge)

COST OF SUBSCRIPTIONS:  MONTHLY $330;  QUARTERLY $110;  SEMI-ANNUAL $55 ( NO DISCOUNTS ON SUBSCRIPTIONS)

* Less Discount Based on Total Profiles Ordered & Shipped at the Same Time to a Single Location

X

$27.50

$

Media

# of Profiles

Cost

Initial Cost

Paper

15%

20%

25%

(

)

2-6 Profiles

7-12 Profiles

13+ Profiles

Discount

3½" Floppy

E-mail - Please Specify

AMOUNT OF CHECK

$

Case Sensitive e-mail address

[Make check payable to:  COmputing TechnologieS, Inc.]

D.

SEND ORDER FORM AND CHECK TO:

COmputing TechnologieS, Inc.

FMCSA Data Dissemination Program

P.O. Box 3248

Merrifield, VA 22116-3248

(703) 280-4001