TYPE OF TRIP PERMIT (check only one)
IRP ($15.00 fee) MOTOR FUEL ROAD TAX ($20.00 fee) COMBINED IRP/ MOTOR FUEL ROAD TAX ($35.00 fee)
APPLICANT FULL NAME (last, first, mi, suffix) BUSINESS/COMPANY NAME
BUSINESS LOCATION ADDRESS (no post office box) CITY STATE ZIP CODE
TELEPHONE NUMBER LESSOR NAME (if leased vehicle)
VEHICLE YEAR MAKE/MODEL UNIT NUMBER VEHICLE IDENTIFICATION NUMBER (VIN)
LICENSE PLATE NUMBER ISSUING STATE EXPIRATION DATE (mm/dd/yyyy) PERMIT REQUESTED DATE (mm/dd/yyyy)
(check one)
CREDIT CARD / E-Check -- provide contact number →
CHECK / MONEY ORDER -- Made payable to DMV
TELEPHONE NUMBER
NOTE: In our continuing effort to safeguard customer information, DMV does not accept credit card payments by mail or email. You may pay with a
credit card by having a Motor Carrier Services Representative contact you. We accept checks and money orders via mail.
PAYMENT METHODS
IRP AND/OR MOTOR FUEL ROAD TAX
TRIP PERMIT APPLICATION
Purpose: Use this form to apply for an IRP, Motor Fuel Road Tax or a Combined Trip Permit.
Instruction: Application MUST be faxed to (804) 367-1073. Trip permits are vehicle-specific and are valid for ten days.
When this application is authorized, enter the following information and then complete an MCTS 273, Trip Permit.
DMV USE ONLY
PERMIT NUMBER EFFECTIVE DATE (mm/dd/yyyy) EXPIRATION DATE (mm/dd/yyyy) AUTHORIZED SIGNATURE
APPLICANT INFORMATION
MCTS 271 (09/01/2015)
FAX PERMIT TO:
FAX NUMBER
EMAIL PERMIT TO:
EMAIL ADDRESS
MAIL PERMIT TO:
ADDRESS (if different from above)
CITY STATE ZIP CODE
CARRIER SIGNATURE
DATE (mm/dd/yyyy)
