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HOUSEHOLD GOODS CARRIERS

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ANNUAL REPORT
Due May 1, 2013

**Not Confidential**

Full name and address of Company

Correct name and address, if different than shown.

WASHINGTON UTILITIES AND TRANSPORTATION COMMISSION
for the
YEAR ENDED DECEMBER 31, 2012
Inquiries concerning this Annual Report should be addressed to:
NAME:

TITLE: _______________________________

ADDRESS: ___________________________________________________________________________
CITY: __________________________________ STATE: _____________ ZIP: _____________________
TELEPHONE: _______________________ FAX: _________________ E-MAIL: ____________________

The company must notify the Commission, in writing, of any changes to the above information.
For Commission Use Only

TYPE OF PAYMENT - DO NOT SEND CASH IN THE MAIL

Credit Card Authorization #:________________
___ Check ___ Money Order ___ AMEX ___ Visa ___ MasterCard ___ Discover
Expiration Date
Credit Card Number:

Month/Year

CERTIFICATION FOR CREDIT CARD PAY