Permit Order Form

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Permit Order Form

Carrier / Registrant Information

Last Name *

First Name *

Physical Address *

Suite/Apt #

City *

State *

Zip Code *

Phone Number *

Fax Number

Email Address *

Mailing Address

Mailing Suite/Apt #

Mailing City

Mailing State

Mailing Zip

EIN *

DOT # *

Vehicle Information

Unit # *

Year *

Make *

VIN *

Vehicle Type *

License Plate / State *

Fuel Type *

Hauling Automotive Fuel *

Yes

Unladen Weight *

Registered Combined Gross Weight *

Owned or Leased?

Owned

Leased

Clear selection

If Leased, provide owner's name

Permit Request(s)

Some permits require additional information. If there is a symbol after your permit selection, please fill include the additional information based on the symbol(s). Permits CANNOT be issued without all necessary information.

Start Date and Time *

YYYY

Time

Permit Request #1 *

*Required for CA, IL

*Highway of Entry

*Where will you enter the state from?

*IFTA Account #

+ Required for GA, IN, MT, SD

+ Insurance Policy Number

+ Insurance Carrier Name

+ Insurance Carrier Full Address (Number, Street, City, State, Zip)

+ Insurance Effective Date

+ Insurance Expiration Date

+ License Plate Expiration Date

# Required For ID, MT, NV, ND, OR, SD

# Entry into State

# Exit out of State

# Destination

# Pick Up or Delivery?

Yes

Clear selection

@ Required For KS, MS, OR, SD, UT

@ Commodity Load Description

= Required For ME, MD

= Number of Axles

^ Required for MT, SD

^ Trailer legnth

^ Trailer Width

^ Trailer Height

< Required for ND, OR

< All Routes in/out of State

> Required For OR

> Odometer Reading

! Required For TX

Certificate of Liability must be faxed in!!

~ Required For SD

~ Trailer Year

~ Trailer Make

~ Trailer VIN

~ Trailer Plate #

& Required For WI

& Trip City of Origin

& Wisconsin Destination City

& Entry Point Highway

& Trip Purpose

Payment Information

Once we receive your permit request, we will send you an authorization form for your payment. All sales are final and permits cannot be cancelled once they are ordered. No refunds will be issued. Questions? Call (704) 941.9653

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