Fillable 72 Hour Trip Fuel Permit- OTR

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72 Hour Trip Fuel Permit- OTR

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The 72 Hour Trip Fuel Permit- OTR form is 1 page long and contains:

  • 0 signatures
  • 7 check-boxes
  • 34 other fields

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File type: PDF

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1
72-HOUR TRIP (IRP) & FUEL (IFTA) PERMIT
IT IS STRONGLY RECOMMENDED THAT YOU USE THE INSTRUCTIONS PROVIDED WITH THIS FORM AS A GUIDE. INCOMPLETE OR
INCORRECT APPLICATIONS WILL DELAY THE ISSUANCE OF DOCUMENTS.
SECTION 1. GENERAL INFORMATION
USDOT NO.
FEIN/SSN (SSN Sole Proprietor Only)
LEGAL NAME
DOING BUSINESS AS (DBA) NAME
PRINCIPAL PLACE OF BUSINESS ADDRESS (Not a PO Box)
STREET
CITY
STATE
ZIP CODE
MAILING ADDRESS (if different than Principal Address, May be a PO Box)
STREET
CITY
STATE
ZIP CODE
PERSON TO CONTACT
FAX NO.
E-MAIL ADDRESS
SECTION 2. 72-HOUR PERMIT TYPE
After processing, an invoice will be sent by fax or e-mail. Call 1.866.831.6277 to pay.
72-Hour Reciprocity Trip Permit
$10.00
72-Hour IFTA Permit
$10.00
72-Hour Trip/Fuel Combination Permit
$20.00
VEHICLE YEAR
VEHICLE MAKE
VEHICLE VIN
REGISTRATION STATE
LICENSE NUMBER
BEGINNING DATE
BEGINNING TIME (HH:MM)
AM
PM
SECTION 3. PERMIT SERVICE INFORMATION (*Required for Permit Service Companies Only*)
COMPANY NAME
CONTACT NAME
COMPANY STREET
CITY
STATE
ZIP CODE
PHONE NO.
FAX NO.
E-MAIL ADDRESS
Service to receive bills, plates, refunds, etc? Yes No
MCE User ID (if applicable)
Agent Signature
If you are using a Permit Service, a Power of Attorney MUST be submitted with this form.
SECTION 4. SIGNATURE
SIGNATURE
DATE
MISSOURI DEPARTMENT OF TRANSPORTATION
E-MAIL
contactmcs@modot.mo.gov
MOTOR CARRIER SERVICES
PHONE
1.866.831.6277
PO BOX 270, 830 MODOT DRIVE, JEFFERSON CITY, MO 65102-0270
FAX
OSOW 573.751.7408
2
72 HOUR PERMIT INSTRUCTIONS
SECTION 1. GENERAL INFORMATION
USDOT Number – Enter the company’s USDOT Number, if applicable. If the company has not been assigned a USDOT number, leave
this field blank.
FEIN/SSN – Enter the Federal Employee Identification Number issued by the Internal Revenue Service. A sole proprietor who does
not have an FEIN should enter a Social Security Number.
Legal Name – Enter the company’s legal name. This name must be the same as what is registered with the FMCSA. Do not enter a
DBA name.
Single Owner: enter the first and last name as shown on birth records.
Partnership: list the legal name of each partner.
Corporation or LLC: enter the unique name that is on file with the company’s state of incorporation.
Doing Business As (DBA) Name – If the company uses a fictitious (DBA) name and is a Missouri based carrier, that name must be
registered with the Missouri Secretary of State. Contact the Secretary of State’s office at 1.800.223.6535 with questions.
Principal Place of Business Address – Enter the address where business and safety records of the company are kept and can be
made available. This must be a physical location, not a PO Box.
Mailing Address – Enter the mailing address, if different than the principal place of business address. This address may be a PO Box.
Person to Contact – Enter the name of the person who will be the contact for the account.
Phone & Fax Numbers – Enter the business telephone and fax numbers for the contact person.
E-mail Address – Enter the e-mail address of the contact person for account correspondence.
SECTION 2. FORM OF BUSINESS
72-Hour Reciprocity Trip ($10.00) – Permit is required for carriers based in another jurisdiction that are not properly licensed to
travel in or through the state of Missouri.
72-Hour IFTA Permit ($10.00) – Permit is required prior to entry or re-entry into Missouri when not registered for IFTA.
72-Hour Combination ($20.00) – Permit is required for carriers based in another jurisdiction that are not properly licensed to travel
in or through the state of Missouri AND are not registered for IFTA.
Vehicle Year – Enter the year of the vehicle.
Vehicle Make – Enter the make of the vehicle.
Vehicle VIN – Enter the VIN of the vehicle.
Registration State – Enter the registration state of the vehicle.
License Number – Enter the license number of the vehicle.
Beginning Date – Enter the date the permit should begin.
Beginning Time – Enter the time the permit should begin. Be sure to choose AM or PM.
SECTION 3. PERMIT SERVICE INFORMATION (*Required for Permit Service Companies Only)
Required for Permit Service Companies Only. Provide all requested information.
SECTION 4. SIGNATURE
The applicant or individual legally authorized to sign on behalf of the applicant must sign and date the form. If a permit service signs this section, a
Power of Attorney must accompany the completed form.
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72 Hour Trip Fuel Permit- OTR

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Completed 4 September 2020

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