MISSOURI DEPARTMENT OF TRANSPORTATION
MOTOR CARRIER SERVICES
830 MoDOT DR., P.O. BOX 270
JEFFERSON CITY, MO 65102-0893
PHONE: (800) 877-8499 FAX: (573) 751-7408
EMAIL ADDRESS: contactmcs@modot.mo.gov
General Information
USDOT#
Contact Person
Contact Telephone Number
Escrow Account Number
Escrow Account
Check
MasterCard
Visa
Discover
American Express
Legal Name of Applicant
Federal Identification Number
DBA Name
Social Security Number
Private or For Hire
Interstate Carrier Intrastate Carrier or Both
Physical Address
City
State
Zip Code
Mailing Address
City
State
Zip Code
Email Address
Telephone Number
Fax Number
Start Date
Send Permit How?
Fax Number
Email
Mail
Financial Responsibility
Minimum Limits of Combined Single Limit Automobile Liability: $750,000
By submitting this application, the permittee certifies that the insurance coverage will be in effect during all the applicant’s operations authorized under this permit.
Permit Fees Prorate by Quarter
Up to 12’4” wide
Legal Weight
Multiple Commodity
Legal Weight
100 Mile Radius
Legal Weight
Emergency Response
Water Well Drill Rig
Concrete Pump
January December
$128.00
$400.00
$128.00
$624.00
$300.00
April December
$ 96.00
$300.00
$ 96.00
$468.00
$225.00
July December
$ 64.00
$200.00
$ 64.00
$312.00
$150.00
October December
$ 32.00
$100.00
$ 32.00
$156.00
$ 75.00
Power Unit Information
Toter Truck Truck-Tractor
License Number
State
VIN
Year
Make
Do you want to revise a current year permit? Yes No
There is a $2.00 Fee
If yes, original permit
or application number
Original License Number
APPLICATION FOR
BLANKET PERMIT
For official use only District Number_______ Permit Number__________________________________ initials _____
Application for Blanket Permit Continued
Blanket permits are only available for 12’4” wide or less (except 100 mile radius). Other restrictions may apply.
See section (7) of the Overdimension and Overweight Permit Regulations Book.
Check appropriate box for each type of blanket permit you are requesting:
Manufactured Home
Hay
Sludge Applicator
Modular Homes
Pipes
Implement of Husbandry
Mod/Mob Home Frames
Poles
100 Mile Radius for Farmers and Farm Implement Dealers up to 14’6” wide
Construction Equipment
Beams
Multiple Commodity
Farm Equipment
Poles (Utility Co. /Co-ops, etc)
Well Drill Rig (overdimension only)
Like Object (i.e. boat, trusses, portable building) Enter Description:
LCV Longer Combination Vehicle (only allowed to move within 20 miles of western border) Route:
Emergency Response enter individual axle weights and spacings:
Axle Weight
1
2
3
4
5
6
7
8
9
Total Weight
Axle Spacings distance center to center between axles
1 & 2
Feet
Inches
2 & 3
Feet
Inches
3 & 4
Feet
Inches
4 & 5
Feet
Inches
5 & 6
Feet
Inches
6 & 7
Feet
Inches
7 & 8
Feet
Inches
8 & 9
Feet
Inches
Total Axle Spacings
If under own power provide the following information:
Description
Year
Make
Serial Number
Water Well Drill Rig Concrete Pump
enter individual axle weights and spacings
Axle Weight
Make
Serial Number
Overall Width
Feet
Inches
Overall Length
Feet
Inches
1
2
3
4
5
6
7
Total Weight
Axle Spacings distance center to center between axles
1 & 2
Feet
Inches
2 & 3
Feet
Inches
3 & 4
Feet
Inches
4 & 5
Feet
Inches
5 & 6
Feet
Inches
6 & 7
Feet
Inches
Total Axle Spacings
Certification
I DECLARE UNDER THE PENALTY OF PERJURY under the laws of the State of Missouri and United States of America that the foregoing information in the application is
true and correct, that I am authorized to sign this on behalf of applicant and that the signature below is my own true and correct signature made by me and no other person.
Name (printed)
Date
Signature
Title
(used primarily for manufactured homes)
General Information
Page 2 Check the appropriate box for each type of blanket permit you are requesting.
INSTRUCTIONS FOR COMPLETING A BLANKET PERMIT APPLICATION
Vehicle Information
USDOT #: Enter your U.S. Department of Transportation Number. If your operation does not require a USDOT number, enter
“XX”. If you don’t know if a USDOT number is required, call the FMCSA at 573-636-3246 or visit www.safersys.org
Contact Person: Enter the name of the person we can call with questions about the application.
Contact Telephone Number: Enter the contact person’s telephone number.
Account Number: Enter the account number assigned to you by MoDOT Motor Carrier Services.
Payment Type: Check a box for escrow account, cash, check or specific credit card. If using a credit card, for security reasons, do
not write the card number on the application. A MoDOT employee will contact you for the information verbally.
Legal Name: Enter your legal name.
NOTE: If you have a MoDOT account number or ordered a permit in the past six months, skip to the Start Date section.
DBA Name: If your business is a sole proprietorship and you are doing business with a fictitious name, enter your business name. If
you are a Missouri-based carrier, you must register this name with the Secretary of State office. You may contact the SOS office by
calling 866-223-6535 or visiting www.sos.mo.gov.
Federal Identification/Social Security Number: Enter your FEIN if applicable. If not, enter your social security number. State law
requires FEIN or Social Security Numbers of sole proprietorships. You must provide a FEIN or Social Security Number to obtain a
permit.
Customer Type: Check one box. Private or For Hire.
Check one box. Interstate Carrier, Intrastate Carrier or Both.
Insurance Information: Insurance Company Name, Policy Number, Expiration Date and amount of coverage (check one box).
Physical Address: Enter the address of your principal place of business.
Mailing Address: Enter your mailing address if it is different from the physical address.
Start Date: Enter the date you want your permit to start.
Send Permit How?: Enter the fax number, mailing address, and/or the e-mail address where you want the permit delivered.
Power Unit: Enter the license number, state it is licensed in, complete vehicle identification number, year and make. Check one box
for power unit type. Examples follow:
Toter Truck Truck-Tractor
Revision: If you want to revise a current year permit, check yes and provide the original permit or application number and original
license number, otherwise check no.
Emergency Response: If under own power, enter serial number and the serial number.
Individual Axle Weights: Enter weights for each axle in pounds.
Axle Space: Enter each individual axle spacing in feet and inches.
Water Well Drill Rig or Concrete Pump Truck: Check appropriate box. Enter make, serial number, overall width and length.
Individual Axle Weights: Enter weights for each axle in pounds.
Axle Space: Enter each individual axle spacings in feet and inches.
Certification: Print your name and the date of application. Sign the form and provide your business title, (i.e. president, owner or
partner).
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