Free Single Trip Application - Wisconsin

SINGLE TRIP APPLICATION
Telephone: 608-266-7320

Log No.-For Dept./Commercial Permit Service Use ONLY Mail To: Wisconsin Department of Transportation Permit Unit P. O. Box 7980 Madison, WI 53707-7980 Multiple Trip Permit No. to Suspend-if Applicable

Do not use this form for mobile homes/modular building sections. MV2604 1/2003 s.348.26(2), (3) Wis. Stats.

Section A - Customer

Please print clearly or type.

Clear Form

1. Permit Customer No. - If Available PC 2. Legal Name - Vehicle Owner or Lessee Mailing Address City State Zip Code

Desired Effective Date

Doing Business As (D/B/A) Federal Employer Identification No. U.S. DOT Number

Contact Name for DOT to call if questions / Area Code - Telephone No.

Section B - Insurance - The customer has sufficient insurance
coverage in full force and effect. Check Group A or Group B. Group A - Combined Single Limit $750,000 Group B - Combined Single Limit $1,000,000

Section C - Load - Describe Article(s) Transported

Required: Is your load radioactive?

Yes
Make

No
Axles Unit

Section D - Vehicles Power Unit - Both Plate/State and VIN must be identified
Plate State Vehicle Identification Number (VIN) __ Truck-tractor __ Truck __ Other: Year

Towed Vehicles - Either Plate/State or VIN must be identified
Plate State Vehicle Identification Number (VIN)

Semi- Full trailer trailer Dollies Other

Year

Make

Axles Unit

Section E - Size
Length Width

Power Unit Ft. in.

Towed Vehicle Ft. in.

Load Ft. in. in.

Front Overhang Ft. in.

Overall Ft. Ft. Ft. in. in. in.

Height Are Gross Vehicle Weight and Axle Weight both legal?

Section F - Axle Weight/Spacing - Tires - by axle, front to rear
Axle Number Number of Pneumatic Tires Requested Gross Axle Weight When Loaded (lbs.) Spacing Between Axles (Ft. Axle Number Number of Pneumatic Tires Requested Gross Axle Weight When Loaded (lbs.) Spacing Between Axles (Ft. in.) in.) 10 11 12 13 14 15 16 17 18 1 (front) 2 3 4 5 6 7 8 9

Section G - Trip: Single trip permits issued by the WIDOT authorize movement on interstate and state trunk highways ONLY.

Original Trip Return Trip
Permit Number

Revised / Amended Permit Number

9876543212109876543 9876543212109876543210987654321098765432121098765432109876543210987654321 9876543210987654321210987654321098765432121098765432109876543210987654321 2109876543210987654321098765432121098765432109876543210987654321 9876543210987654321210987654321098765432121098765432109876543210987654321 2109876543 9876543210987654321 876543210987654321 5432121098765432109876543210987654321 432121098765432109876543210987654321 9876543210987654321 5432121098765432109876543210987654321 9 5
Ft. Yes - Skip Section F No - Complete Section F - Give

overall weight:

From City, Village, Township Via Highways - continued

To City, Village Township

Via Highways

Are the return dimensions and route the same as the "Original Trip"? ____ Yes ____ No, On a second application, complete Sections A 1, A 2, B, E, F, and G. Acceptance of Conditions: I certify that the statements contained in the application are true and correct and I will comply with all terms and conditions.

X

(Customer or Authorized Agent)

(Date)