Dc Trip Permit Form – Fill Out and Use This PDF

GOVERNMENT OF THE DISTRICT OF COLUMBIA

DEPARTMENT OF MOTOR VEHICLES

95 M Street, SW, Washington, DC 20024

REQUEST FOR DC TRIP PERMIT

International Registration Plan (IRP)

Phone Number: 202-729-7083					E-mail: dcirpdmv@dc.gov
$50.00 TRIP PERMIT IS VALID FOR SIX (6) CONSECUTIVE DAYS
			(PLEASE PRINT)
APPLICANT INFORMATION
LAST NAME			FIRST NAME					MIDDLE NAME		SUFFIX
BUSINESS INFORMATION
BUSINESS NAME								FEIN
STREET ADDRESS ( NO P.O. BOX NUMBERS)			CITY					STATE	ZIP CODE
TELEPHONE NUMBER W/AREA CODE								E-MAIL ADDRESS

VEHICLE INFORMATION

EFFECTIVE/EXPIRATION DATES AND TIME

(PERMITS ARE NOT TRANSFERABLE)

METHOD OF PAYMENT ( MONEY ORDERS AND CHECKS MADE PAYABLE TO: DC TREASURER)

MONEY ORDER

CHECK #: _______

MASTERCARD*

VISA*

DISCOVER CARD*

*I authorize payment with my credit card for DC DMV Trip Permit transactions.

NAME AS IT APPEARS ON CREDIT CARD:

CARD NUMBER:		EXPIRATION DATE:			TOTAL AMOUNT: $
PREFERRED METHOD OF DELIVERY (INDICATE COURIER AND RATE TO BE BILLED)
PICK UP(MON-SAT 8:15 AM - 4:00 PM)		REGULAR MAIL	EXPRESS SERVICE: CUSTOMER ACCOUNT #: __________________
FED EX SERVICE		DHL SERVICE		UPS SERVICE	CREDIT CARD
PRIORITY OVERNIGHT	SAME DAY			NEXT DAY	MASTERCARD*
STANDARD OVERNIGHT	TIME DEFINITE: ________			STANDARD GROUND	VISA*
OTHER:_________	DAY DEFINITE:________			EXPRESS OVERNIGHT	DISCOVER CARD*
	OTHER:______			OTHER:___________

(IF DIFFERENT FROM ABOVE): CARD NUMBER:EXPIRATION DATE:

Any person using a fictitious name or address and/or knowingly making any false statement on this application is in violation of D.C. Law and subject to a fine of not more than $1,000 or 180 days imprisonment or both. (D.C. Official Code §22-2405).

I hereby certify, under penalty of perjury, that the information contained on this application is true and correct.

APPLICANT SIGNATURE:	DATE:
DMV AUTHORIZING OFFICIAL SIGNATURE AND DATE	AUTHORIZIED PERMIT NUMBER

To report waste, fraud, or abuse by any DC Government Agency or official, call DC Inspection General at 1-800-521-1639.

Visit our website: www.dmv.dc.gov or call 311 or 202-737-4404 for additional information.

DCDMV-Trip Permit – 01 Rev. 08/13/09