Minnesota Department of Public Safety State Patrol Division
Fill out information to the right.
Please type or print your name and mailing
address legibly. It will be used as your return
Company Telephone Number
Company Name
Mailing Address
City State Zip Code
If you have any questions about the decal order, please call the Minnesota State Patrol at (651)350-2000.
Credit Card Orders: For your security, we do not accept credit card orders by e-mail or fax. Please mail your order to the above
address. A service charge of $4.50 is assessed for each credit card order.
_______________________________________________________________________ _____________________
Credit Card Number Month/Year
It is hereby agreed this inspector will recognize the critical criteria established by the State Patrol Division of the Department of
Public Safety, and shall place decals only upon vehicles that have passed inspection as provided by law.
Should it ever be determined this inspector has issued decals without regard to all provisions set forth in 49 CFR 396.17 and
MS 169.781, the privileges of performing certified inspections may be revoked.
Decals listed below are to be used only by the inspector who has signed this form. Use by any other person is strictly prohibited.
Agreed by:
_________________________________________________ ________________________________________________
Certified Inspector’s Signature Date Inspector Certification Number
_________________________________________________ ________________________________________________
Print Inspector Name Company Name
For Office Use Only
Beginning Decal # ______________________________ Ending Decal # ______________________________
Transaction Type________________ Check # ________________________ Date Issued________/________/
20____ Issued by:___________________
(Revised 01/09/2019)
Decals are available for the current year and one preceding year. Decals for the succeeding year
will be available beginning November 15. Decals are not refundable or exchangeable. Please
order carefully.
What year decals do you want to purchase? _______________
How many decals do you want to purchase? _______________
Decals are $2.00 each. Total due for decals $_______________ (Do not include credit card fee.)
Make check or money order payable to STATE OF MINNESOTA.
Mail order form and remittance to:
MN State Patrol Commercial Vehicle Section
1110 Centre Pointe Curve #410
Mendota Heights, MN 55120
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