Minnesota Fuel Permit Application Form – Fill Out and Use This PDF

	MINNESOTA DEPARTMENT OF PUBLIC SAFETY
	DRIVER AND VEHICLE SERVICES
	445 Minnesota Street
	Saint Paul, MN 55101-5188	Office Use Only
	Phone: (651) 205-4141 TTY: (651) 282-6555 Fax: (651) 797-1187
		Permit Number
	Web: dvs.dps.mn.gov

	EFFECTIVE DATE
Check the box for for the permit(s) you are requesting.
120	Hour Trip Permit ($15, plus $10 filing fee) - One permit per vehicle every 30 days; issued up to 80,000 lbs.
120	Hour Fuel Trip Permit ($25, no filing fee) - No limit to the number of permits issued.
120 Hour Unladen Weight Hunters Permit ($10 filing fee only) - Effective date is the date of issuance; certain restrictions apply.
Temporary Weight Increase ($4.17 per ton per 30 days, rounded to the nearest whole dollar, plus $10 filing fee)
	**Select temporary weight increase duration:		30 DAYS	60 DAYS		90 DAYS
	**Beginning Minnesota Registered Weight:					**Increase to:

NOTE: A temporary weight increase does not replace the requirements for an overweight permit authorized by MnDOT and/or local road authority.

Base Plate Permit (See page 2 for registration fees based on duration, weight & model year of vehicle, plus $10 filing fee)

**Select base plate permit duration:	30 DAYS		60 DAYS	90 DAYS
**Registered weight being requested on permit:

Section II - Vehicle Information

Vehicle Identification Number:

Model Year:

Make:

Select type of vehicle:

Truck tractor

Truck

Bus

**If applying for Unladen Weight Hunters permit, indicate the most recent Minnesota IRP plate

Number of axles:

USDOT Number:

(not required to be submitted for fuel or Unladed Weight Hunters permit)

**If no plate number provided, please indicate reason:

**Indicate those that apply:

I am verifying that the vehicle is less than 26,001 pounds while conducting Intrastate travel in Minnesota (verification is required if applying for Trip or Base Plate permit)

Vehicle listed above is not required to provide USDOT number as it is registered in the MN farm class, displays a MN farm plate, only traveling within the state of Minnesota and not doing any Interstate movement as defined by the Federal Motor Carrier Safety Administration.

Section III - Registered Owner and Contact Information

Name (first, middle, last):

Street address:

City:

State:

Zip code:

Contact information required for DVS to contact you with questions or issues regarding processing of the permit.

Contact Name:

Contact Phone Number:

Fax Permit to:

	Fax number must be provided in order to receive credentials
PS2268-07 (12/13)	-OVER-

Minnesota Temporary Registration / Fuel Permit Application - Page 2

Section IV: Data Privacy Statement

DATA PRIVACY STATEMENT:

Information collected to issue this permit is used to:

•Identify the owner of the vehicle

•Identify the person applying for the permit

•Identify the motor vehicle to which the permit is issued

You are not required to submit the information. However, if you do not submit the information the Department of Public Safety cannot issue a vehicle permit. Personal information (name and address of individuals) is classified as private data. The Department of Public Safety releases this information only as authorized or required by state and federal law. Access to motor vehicle records is governed by:

•Minnesota Statues, chapter 168.346

•United States code title 18, sections 2721-2725 and Minnesota Statues, chapter 13

Section V: Fees

Request by fax must have a properly completed Electronic Funds Authorization form attached along with a copy of a voided check. Please contact Driver and Vehicle Services if you have any questions on payment

Permit Fees are listed on page one with the exception of the Base Plate Permit:

Base plate permit is a $10 filing plus the monthly registration fees listed below.

GVW IN POUNDS	FIRST 8 MODEL YEARS	9th MODEL YEAR	10th MODEL YEAR & OLDER
12,000 - 15,000	$10	$10	$10
15,001 - 18,000	$12	$12	$12
18,001 - 21,000	$16	$15	$12
21,001 - 26,000	$23	$22	$17
26,001 - 33,000	$30	$29	$23
33,001 - 39,000	$40	$38	$30
39,001 - 45,000	$50	$48	$37
45,001 - 51,000	$60	$57	$45
51,001 - 57,000	$72	$69	$54
57,001 - 63,000	$85	$81	$64
63,001 - 69,000	$99	$95	$74
69,001 - 73,280	$110	$106	$83
73,281 - 78,000	$133	$127	$100
78,001 - 80,000	$147	$141	$110

Over 80,000 pounds; +4.17 per ton, per month (rounded to the nearest whole dollar)

PS2268-07 (12/13)