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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