Maine Trip Permit Application Form – Fill Out and Use This PDF

Department of the Secretary of State

Maine Bureau of Motor Vehicles

72 Consecutive Hour

Trip Permit Application

Permit Information:

Effective Date & Time	Expiration Date & Time
/	/

I am applying for the following:

IRP Trip Permit ($25.00 + $3.00 Fax Fee)

IFTA Fuel Trip Permit ($50.00 + $3.00 Fax Fee)

Combination IRP/IFTA Trip Permit ($75.00 + $3.00 Fax Fee)

Carrier Information:

Registrant Name: ________________________________________________

Address: _______________________________________________________

City: _____________________ State/Province: _____ Postal Code: ________

Carrier Responsible for Safety US DOT Number:1 _______________________

Vehicle Information: (A copy of the Valid Registration must be provided.)

Year	Make	Maine Reg. Wgt.	Axles VIN Number
Base Jurisdiction		Plate Number	Unit Number

Contact Information:

Person Requesting Trip Permit	Phone Number
Fax Trip Permit To (Name)	Fax Number

1If you are leased to another carrier, you are required to provide a copy of the lease agreement.

**The following payment information MUST be provided**

Type of card: (please circle one) VISA Mastercard

Account Number: __________________________ Exp. Date: ______________

Cardholder Name: _________________________________________________

Billing Address: ___________________________________________________

Telephone Number (Cardholder): _____________________________________

Signature: ________________________________________________________

REVISED 7/06/2012

101 Hospital Street, 29 State House Station, Augusta, ME 04333-0029

Phone (207) 624-9000 Ext. 52135 Fax (207) 624-9086 TTY Users call Maine relay 711

www.maine.gov/sos/bmv/commercial Email: meirp@maine.gov