Please Send This in by Email to Or by Faxing in to One of the Fax Numbers Listed Below

This is only a Permit Application and is not valid for travel. Permits will be issued as ordered by close of the next business day. To immediately obtain a permit, visit our website at www.mdt.mt.gov and use our online permitting system. Please send this in by email to [email protected] or by faxing in to one of the fax numbers listed below.

“SINGLE TRIP” - PERMIT TYPE REQUEST Revised 06/13/2017 32J LOG NUMBER SELECT TRIP 32J APPROVED APPLICATION PERMIT TYPE OF *IF PERMIT IS FOR A 32J, ALL INFORMATION LISTED BELOW MUST PERMIT MATCH THE 32J APPLICATION SUBMITTED, APPROVED AND ON FILE ELECTRONIC REF NEEDED: WITH MCS*. #

COMPANY INFORMATION ACCOUNT # USDOT # TIN/FEIN # LEGAL NAME DBA NAME

BUSINESS ADDRESS (STREET, CITY, STATE, ZIP CODE)

CONTACT NAME / PERMIT SERVICE PHONE NUMBER

EMAIL PERMIT TO: FAX NUMBER

INSURANCE CARRIER POLICY NUMBER EXPIRATION DATE LIABILITY $$

PERMIT START DATE: PERMIT END DATE: DOES THIS TRUCK HAVE IFTA (INTERNATIONAL FUEL TAX AGREEMENT)? (IF YOU ARE A MT BASED CARRIER YOU DO NOT NEED THIS) YES NO

VEHICLE / LOAD INFORMATION LOAD DESCRIPTION: ARE TRAILERS, IF APPLICABLE, CURRENTLY REGISTERED? YES NO ENTER THE: TRAILER PLATE STATE OVERALL WIDTH OVERALL LENGTH OVERALL HEIGHT TRAILER LENGTH REAR OVERHANG

ARE YOU APPLYING FOR: LEGAL WEIGHT or OVERLEGAL WEIGHT (ENTER INFORMATION BELOW)

LEGAL WEIGHT OVERLEGAL WEIGHT IF LEGAL WEIGHT, WHAT IS THE COMBINED GROSS VEHICLE (ENTER AXLE SPACINGS & WEIGHTS WEIGHT: BELOW).

Licensing & Permitting Bureau Phone: (406) 444–6130 Fax: (406) 444–7670 or 444-0800 or 444-9263 Page 1 of Term Permit Request Application An Equal Opportunity Employer Motor Carrier Services Division TTY: (800) 335–7592 www.mdt.mt.gov Licensing & Permitting Bureau Phone: (406) 444–6130 Fax: (406) 444–7670 or 444-0800 or 444-9263 Page 2 of Term Permit Request Application An Equal Opportunity Employer Motor Carrier Services Division TTY: (800) 335–7592 www.mdt.mt.gov LEGAL NAME ACCOUNT #

LIST CURRENT TERM PERMIT NUMBERS WITH MT: OVERSIZE TERM 120 FT NON-DIVISIBLE TERM COMPLETE VIN: PLATE: UNIT: YEAR: MAKE: JURISD.: VEH TYPE:

AXLE SPACINGS AND WEIGHTS (LISTED IN FEET AND INCHES) VEHIC LE ANAL YSIS NUMB BCL 10MPH REGULAR ER (IF APPLI CABLE ): 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12

STEERI DRIVES JEEP TRAILER BOOSTER NG

Make sure each applicable field is completed. Incomplete fields may result in a delay of your permit being processed.

IS THIS TRUCK APPORTIONED FOR MONTANA; OR IS THIS VEHICLE A MT COUNTY PLATED VEHICLE? YES NO IF YES, AT WHAT WEIGHT?

IF NOT APPORTIONED FOR MONTANA, ENTER REGISTERED GVW FROM BASE JURISDICTION: ORIGINATION (STATE LINE, CITY, DESTINATION (STATE LINE, CITY, VIA ROUTE: MILES FROM CLOSEST CITY): MILES FROM CLOSEST CITY):

PAYMENT INFORMATION (CREDIT CARD OR E-CHECK)

FIRST NAME: LAST NAME: COMPANY NAME:

BUSINESS ADDRESS (STREET, CITY, STATE, ZIP CODE) PHONE NUMBER

*CREDIT CARD # TO BE USED: CREDIT CARD EXP DATE: MONTH YEAR

Licensing & Permitting Bureau Phone: (406) 444–6130 Fax: (406) 444–7670 or 444-0800 or 444-9263 Page 3 of Term Permit Request Application An Equal Opportunity Employer Motor Carrier Services Division TTY: (800) 335–7592 www.mdt.mt.gov NAME ON CREDIT CARD / ACCOUNT: Types of credit cards that MDT accepts are: Visa, MasterCard, Discover and American Express.

*ELECTRONIC FUNDS: ROUTING #: ACCOUNT #: CHECKING or SAVINGS

* When Electronic Payment such as credit card or E-Checks are used, the credit card fee is passed onto the carrier.

MDT Section Only: Completed by: (Name and Uxxxx) Permit Number:

Licensing & Permitting Bureau Phone: (406) 444–6130 Fax: (406) 444–7670 or 444-0800 or 444-9263 Page 4 of Term Permit Request Application An Equal Opportunity Employer Motor Carrier Services Division TTY: (800) 335–7592 www.mdt.mt.gov