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Click ‘Get Form’ to open it in the editor.
Begin by entering the Docket Number at the top of the form. This is essential for identifying your request.
Fill in the name of the carrier, freight forwarder, or broker making the request. Ensure accuracy as this identifies who is requesting revocation.
Provide the complete address of the requesting carrier, including street, city, state/province, and postal code. This information is crucial for processing your request.
Select the authority type by checking all applicable boxes: Common, Contract, or Broker. This specifies what type of authority you are requesting to revoke.
In the 'Reason for request of revocation' section, clearly state your reasons. This helps clarify your intent and supports your application.
Complete the section for the authorized person's name and daytime telephone number. This ensures that FMCSA can contact you if needed.
Sign and date the form where indicated. Remember that a notarized signature is required or it must be signed in front of an FMCSA staff member.
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