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Subcontractor Register Renew

Trucker/Supplier Register Renew

Illinois Department of Transportation
Trucker/Supplier Registration Form

Please Note: Fields marked by an asterisk are mandatory

Please Fill out the form, then click on the "Submit" button

*Type Of Firm	Select One Supplier Trucker
*Firm Name
*Firm Address

*City				*State				*Zip

*Contact First Name			Contact MI			*Contact Last Name

*Tax ID Type	Select One FEIN SSN			*Tax ID

*Contact Phone		Fax		*Email

*Annual Gross Revenue
*Date Firm Established
*Form of Organization	Select One Sole Proprietorship Partnership Corporation Limited Liability Company Other
*Owner Number 1		Owner Number 2
Owner Number 3		Owner Number 4
Owner Number 5		Owner Number 6
*Minority Status	Select One DBE NON-DBE
*Race of Majority Owner	Select One American Indian or Alaskian Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White
*Gender of Majority Owner	Select One Male Female Unspecified or Another Gender Identity

*How many trucks do you own?
*Do you have Leases on any trucks?	Select One Yes No
*Do you have a ICC license number?	Select One Yes No

*Supplier Categories (Select all that apply)
Manufacturer
Regular Dealer
Distributor
Broker
*Do you own distribution equipment?	Select One Yes No

		* I certify the information provided is correct and true to the best of my knowledge.