VIRGINIA EXEMPT BLANKET
HAULING PERMIT APPLICATION
Telephone: (804) 786-2787 ● Fax: (804) 367-1003
Purpose: Use this form to apply for an exempt hauling permit covering multiple moves.
Instructions: Mail or fax this form to the address or fax number above. See page 2 for additional instructions.
DMV USE ONLY
RECEIVED DATE (mm/dd/yyyy) |
REFERENCE NUMBER |
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CHECK NUMBER |
CHECK AMOUNT |
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SHIPPER
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New Shipper Location |
Shipper Address Change |
ID NUMBER (VAHPS ID, FEIN, OR SSN) |
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GOVERNMENT MOVE (check one) |
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STATE |
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LOCAL |
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CONTACT PERSON NAME |
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TELEPHONE NUMBER |
FAX NUMBER |
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COMPANY NAME |
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MAILING ADDRESS |
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P. O. BOX, SUITE NUMBER (if applicable) |
CITY |
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STATE |
ZIP CODE |
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VA JURISDICTION (county or city—VA only) |
COUNTRY |
EMAIL ADDRESS |
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VEHICLE INFORMATION
VEHICLE LICENSE PLATE NUMBER |
ISSUING STATE |
VIN / SERIAL NUMBER (last 5 digits) |
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EXEMPT PERMIT INFORMATION
Indicate permit type requested (check one): |
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Arlington County Trucks (2 Axles) ($130.00 one year) |
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Forest Products ($130.00 one year) |
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Arlington County Trucks (3 Axles) ($130.00 one year) |
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Sand/Gravel/Crushed Rock ($70.00 one year) |
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Articulated Buses (Minimum 3 Axles) ($130.00 one year) |
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Solid Waste (2 Axles) ($130.00 one year) |
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Concrete Haulers (3 Axles) ($130.00 one year) |
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Solid Waste (3 Axles) ($130.00 one year) |
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Concrete Haulers (4 Axles) ($130.00 one year) |
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Specialized Mobile Equipment - Well Tender Machine |
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Containerized Cargo -- ($130.00 one year) |
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(Minimum 3 Axles) ($130.00 one year) |
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Cotton Module (Minimum 3 Axle) ($45.00 one year) |
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Specialized Mobile Equipment - Underground Pipe Cleaning, |
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Excavated Material (3 Axles) ($130.00 one year) |
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Hydro-excavating and Water Blasting Machinery (minimum 3 |
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Excavated Material (4 Axles) ($130.00 one year) |
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Axles) ($130.00 one year) |
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Feed Hauler ($130.00 one year) |
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Virginia Grown Farm Produce ($45.00 one year) |
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Fluid Milk ($130.00 one year) |
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Tank Wagon (2 Axles) -- ($130.00 one year) |
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Boat/Watercraft ($130.00 one year) |
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Provide the requested permit effective date and duration below:
REQUESTED EFFECTIVE DATE (mm/dd/yyyy) EXEMPT PERMIT DURATION |
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ONE YEAR |
TWO YEARS |
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
AUTHORIZED REPRESENTATIVE NAME (print) |
AUTHORIZED REPRESENTATIVE SIGNATURE |
DATE (mm/dd/yyyy) |
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DELIVERY (For current pricing, refer to Virginia hauling permit price list available on our website.)
DELIVERY (check one) |
(NOTE: For payment and delivery information please refer to the instructions on page 2 of this application.) |
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USPS |
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FAX |
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EMAIL (enter your email →) |
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HP 402 (10/27/2020)
INSTRUCTIONS
SHIPPER
•New Shipper Location — Check if this shipper has not been previously issued a permit in Virginia Automated Hauling Permit System (VAHPS) or if it is an additional location for this shipper.
•Shipper Address Change — Check if this application records an address change.
•ID Number — If the shipper has a VAHPS ID, enter it here. Otherwise enter the shipper's federal employer identification number (FEIN) or social security number (SSN).
•Government Move — Choose federal, state, or local if this permit is being ordered to conduct a government move.
•Contact Person Name — Name of the person responsible for the permit. (Contact person name will be displayed on the permit document.)
•Company Name — Name of the shipper.
•Telephone Number — Phone number for the contact person displayed on the permit document.
•Mailing Address — Mailing address for the shipper.
•Fax Number — Fax number of the shipper.
•P.O. Box, Suite Number — Post office box and/or suite number if applicable.
•Email — Email address of the contact person.
•City — City where the shipper is located.
•State — State where the shipper is located.
•Zip Code — Postal zip code where the shipper is located.
•VA Jurisdiction — County or city where shipper is located (for Virginia shippers only).
•Country — Country in which the shipper is located.
VEHICLE INFORMATION
•Vehicle License Plate Number
•Issuing State - where plate was issued
•VIN/Serial Number - Vehicle identification number or last 5 digits of vehicle's serial number.
EXEMPT PERMIT TYPE
•Check the permit type.
CERTIFICATION
•Name — Print the name of the person completing this application.
•Signature — Written signature of the person completing this application.
•Date — Date application was signed.
DELIVERY
•Check the requested delivery method. Mail payment with completed application. For credit card payment, fax or mail the application and the Hauling Permit Office will contact you for payment when the permit is ready to be processed.
