Department of the Secretary of State
Maine Bureau of Motor Vehicles
72 Consecutive Hour
Trip Permit Application
 Permit Information:
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:
Carrier Information: 

Registrant Name: ________________________________________________
Address: _______________________________________________________
City: _____________________ State/Province: _____ Postal Code: ________
Carrier Responsible for Safety US DOT Number:1 _______________________
 Vehicle Information:
Vehicle Information: 
 (A copy of the Valid Registration must be provided.)
 (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:
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