Carrier Complaint Form

Form utilized by the public to file a complaint on a commercial motor vehicle carrier

* Indicates Required Field

Date of Incident:
(Format: mm/dd/yyyy)

Complainant Information

Your Name:

Your Address:

Your City:

Your State:

Your Zip Code:
(no dashes e.g. 555554444)

Your Phone Number:
(no dashes e.g. 5554443333)

*Who are you?

*Nature of Complaint:

Company Information

In order to process the complaint, please provide as much carrier information as possible.

Company Name:

Company Phone Number:
(no dashes e.g. 5554443333)

Company Address:

Company City:

Company State:

Company Zip Code:
(no dashes e.g. 555554444)

USDOT Number:

*Is this carrier a Hazmat carrier?

Yes
No
I don't know

*Is this carrier an Interstate carrier?

Yes
No
I don't know

*Is this carrier an Intrastate carrier?

Yes
No
I don't know

*Is this carrier a passenger carrier?

Yes
No
I don't know

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