Free Multiple Trip Permit Application - Wisconsin

MULTIPLE TRIP PERMIT APPLICATION
To transport large / heavy articles MV2612 5/2006 s.348.26(2), (3) Wis. Stats. Complete a Separate Application for Each Power Unit Section A - Customer Please print clearly or type. 1. Permit Customer No. - If Available PC 2. Legal Name - Vehicle Owner or Lessee Mailing Address City State ZIP Code

Log No.-For Dept./Commercial Permit Service Use ONLY Mail To: Wisconsin Department of Transportation Permit Unit PO Box 7980 Madison, WI 53707-7980

Clear Form

Telephone: 608-266-7320 Make check payable to: Registration Fee Trust 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 - Load - Check only ONE - Please complete a separate application for each permit type desired for this power unit.
Miscellaneous equipment, machinery, and materials; or vehicle under its own power (ex.: construction equipment) s.348.27(2) Garbage or refuse, recyclable scrap s.348.27(9r), s.348.27(12) Michigan border (misc. commodities) s.348.27(9) Potatoes for seed s.348.27(9t) Grain, coal, iron ore concentrates or alloyed iron s.348.27(10) Other- Specify: Number of Months Desired

Boat s.348.27(2) Wis. Stats. Fruits, vegetables, raw forest products s.348.27(9m)(a)1 Raw forest products only at 98,000 s.348.27(9m)(a)4 Permit Effective Date - Desired Start Date: When application received at Wisconsin Department of Transportation List other date in future: (Not to exceed 60 days in the future)

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

Towed Vehicle:

Check this box if you are towing a vehicle For Cranes: If you are using a dolly, is it:

Non-steerable

Steerable

Identify both Plate/State and VIN below for Permit Type: "Potatoes for seed" ONLY Plate State Vehicle Identification Number (VIN) __ Semi-Trailer __ Full Trailer

Year

Make

Axles Unit

Section D - Size - Overall Permit Size(s) and Weight Desired for Vehicle AND Load
Length Width Height Weight

Section E Insurance - The customer has the insurance coverage indicated 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 F - Axle Weight/Spacing - Tires - by axle, front to rear - Complete ONLY if your:
Load from the above list is "Garbage or refuse, recyclable scrap", or "Potatoes for seed" Power unit is an oversize / overweight self-propelled vehicle such as a crane, well-digger, etc. Axle Number Number of Pneumatic Tires Per Axle Maximum Gross Weight Per Axle Spacing Between Axles 1 (front) 2 3 4 5 6 7 8 9

Section G - Route - If applicable, describe on a separate sheet and attach.
Acceptance of Conditions: I, the customer or authorized agent, certify that the statements contained in the application are true and correct. I understand that any multiple trip permit is granted subject to the conditions stated in Chapter Trans. 230, 251, 253, 255, 258, 259, and / or 269 WI Admin. Code and if granted a permit, I will comply with all terms and conditions.

X
Transfer - Give previous permit number (Customer or Authorized Agent) FOR DEPARTMENT USE ONLY - Permit Numbers (Date)

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