INFORMATION - PDF document

1 CUSTOMER INFORMATION SHEET trucker
CUSTOMER INFORMATION SHEET truckersinfo@tbsokc.com Client Number (For TBS Use Only) Name of your Company: Type of Company (circle one): Corporation – Partnership – LLC – Sole Proprietor Primary Contact Position (circle one): Owner – Manager – President – Other Cell Phone Office/Home_ Fax Number Spouse/Other Name: Email address (s) Mailing Address: (City, State) (Zip Code) (County) Physical/Overnight Address: If different from mailing address (City, State) (Zip Code) (County) Primary Social Security # Company Federal Tax ID #: MC #: MC Pin # US DOT # DOT Pin# How many miles traveled last year? List of commodities ( ALL) How many trucks do you own? Trailers How many trucks leased on to you? Trailers How did you hear about TBS? LIMITED POWER OF ATTORNEY TO ALL PERSONS, be it known, that I, , (“INDIVIDUAL”) individually and on behalf of (“COMPANY”) as Grantor, do hereby make and grant a limited power of attorney to Truckers Bookkeeping Service, LLC, Oklahoma City, Oklahoma (“TBS”) and TBS employees, which include Linda Baggett, Hailey Benton, Jo Biddle, Berny Camberos, Aileen Cunliffe, Denise Duck, Tami Gary, Dennis Kaufman, Wood Kaufman, Angela Little, Tasha Marshall, Stepha nie Smith, Gina Spurgeon, Mayra Tello, Cynthia Urbina, Conna Weaver & Carri Wright (“TBS EMPLOYEES”), and appoint and constitute said entity, TBS, and individual persons, TBS EMPLOYEES, as my Attorney - In - Fact, with full power and authority to sign reports and applications, to receive correspondence, to appear on behalf of and represent COMPANY in any administrative hearing or audit of the Oklahoma Tax Commission or any other governmental entity, to pay taxes and fees on behalf of COMPANY, pertaining to fue l ta

2 xes, vehicle registrations and titles, m
xes, vehicle registrations and titles, motor carrier authorities, motor vehicle permits, road use taxes, state business registrations, state payroll withholdings, state unemployment insurance, state workers compensation insurance, Oklahoma Secretary of State filings, any other state applications, or any other documents which pertain to the above noted matters. In the event any of the above listed TBS EMPLOYEES terminate employment with TBS, that individual person shall no longer be authorized to transac t business for COMPANY under this limited power of attorney. The authority granted shall include such incidental acts as are reasonably required or necessary to carry out and perform the specific authorities and duties stated or contemplated herein. COMPA NY and INDIVIDUAL acknowledge this power of attorney does not, in any way, relieve or absolve COMPANY or INDIVIDUAL of its duties and responsibilities under applicable law. In consideration for the duties to be performed by TBS and TBS EMPLOYEES under the terms of this limited power of attorney, COMPANY and INDIVIDUAL, its successors and assigns, hereby release TBS and TBS EMPLOYEES from all claims, disputes, causes of action and assessments that may arise as a result of an audit, investigation, proceeding, or other action taken against the COMPANY by the Oklahoma Tax Commission, other governmental agency, quasi - governmental entity, person, or entity. Furthermore, if services are rendered under this power of attorney, COMPANY and INDIVIDUAL promise to pay fo r such services no later than 30 days of the invoice date. If fees for services rendered are not paid within 30 days, COMPANY and INDIVIDUAL may be assessed additional fees for interest, collection costs, attorney fees, and court costs, and COMPANY and IND IVIDUAL agree to pay such additional charges. This power of attorney and agreement shall continue in full force and effect until revoked by subsequent writing. Signature - INDIVIDUAL/Grantor Name, Position (please print) COMPANY (please pr

3 int) Date Name: Re
int) Date Name: Return To: 405 - 488 - 1999 Fax #: Truckers Bookkeeping Service, L.L.C. Client #: PO Box 18109 Attn: Oklahoma City, OK 73154 FAX (405) 488 - 1999 truckersinfo@tbsokc.com I hereby agree that Truckers Bookkeeping Service, L.L.C. (TBS) has or will be providing the following services and/or goods described below: Enter the amounts from the renewal form below Amount FMCSA Portal Account $74.99 To pay by cashier’s check, pay this amount Subtotal $74.99 Service Fee 3.5% $2.62 Total $77.61 In consideration for the above charges, I authorize TBS to charge the below credit card: Please print ALL of the following information: If the cardholder is different than the applicant, please send a copy of the cardholder’s driver license. 1. Cardholders name: (Not the bank name) 2. Type of card (visa, etc): Expiration date 3. Card number: _ 4. 3 digit security number (last 3 on back of the credit card) 5. Credit card billing address _ Cardholder acknowledges receipt of goods and/or services in the amount of the Total shown hereon and agrees to perform the obligations set forth in the Cardholder’s agreement with the Issuer. X Cardholder/Purchaser Sign Here Date: Call for information about the other services we offer: Factoring , MC (aka ICC), IRP, UCR, 2290 processing, Permits Insurance, Compliance, Dispatch & Fuel Tax Reporting. Fax 405 - 488 - 1999 or truckersinfo@tbsokc.com USDOT # Company Official User Certification 1. T he U SDO T# C o mpany O fficia l is r esponsib l e for e n sur i ng all FMCSA Portal accounts for US D OT # Company Users are current and accurate. This includes approving USDOT# Company User accounts, deactivating that the accounts when a USDO T # Com p a n y User l e aves the c om pany, a n d e nsu r i ng app ro priate roles and access are assigned to USD OT # Company Users . 2. The Company Official

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is responsible for ensuring that proper security measures are in place s o th at i n formation i s not o btai ned by una uthor ized perso ns. This inclu des preventing the sharing of passwords as we ll as preventing passwords being posted where others can see them as we ll as physical security of the access points for FMCSA information. 3. The Co m pany Officia l i s responsib l e for ensuring that each au th orized US D OT# Company User uses t h eir individual u ser ID for every query they run and that they do not share IDs. 4. The Co m pany Officia l i s r espons i ble for updating n ew users , u sers l eaving the company , change in u se r status , or rights and if the se duties are not perfo1med the designated oversight person’s authority could be removed. 5. The Company O ffic i al is req u ired to certify annually that the li st of pe r sons on the User Status Report provided by FMCSA are still approved users in the employ of , or under contract o r agreement with, that company. The r eport will be sent to the Company Official v i a e m a il. Fa ilur e to provide th e a n n ual certifications cou ld result in an aud i t follow - up by FMCSA to recommend whether the company has adequate ove r sight of usage, whether access for t h e i r user s should be terminated, or the Company Offic i al s h ou l d be removed from that function . 6. The Company Offic i a l will r eport any security problems o r passwo r d compromises immediately to the F MCSA Information Systems Security Officer (ISSO) at FMCSA Headquarters (MC - RIS) and local FMCSA IT security personnel. 7. The Company O fficia l w ill inactivate all USDOT# User's accounts when security problems or password compromises have been discovered. I understand my rol e s and res p onsibiliti e s, as US D OT # Compa n y O fficia l , as defined above. Signature - ------------------- Date _ _ _ _