HP 402 (10/27/2020)
TELEPHONE NUMBER
Specialized Mobile Equipment - Underground Pipe Cleaning,
Specialized Mobile Equipment - Well Tender Machine
Virginia Grown Farm Produce ($45.00 one year)
Solid Waste (3 Axles) ($130.00 one year)
Solid Waste (2 Axles) ($130.00 one year)
Fluid Milk ($130.00 one year)
Sand/Gravel/Crushed Rock ($70.00 one year)
Excavated Material (4 Axles) ($130.00 one year)
Excavated Material (3 Axles) ($130.00 one year)
Cotton Module (Minimum 3 Axle) ($45.00 one year)
Containerized Cargo -- ($130.00 one year)
Arlington County Trucks (2 Axles) ($130.00 one year)
Arlington County Trucks (3 Axles) ($130.00 one year)
Articulated Buses (Minimum 3 Axles) ($130.00 one year)
Concrete Haulers (3 Axles) ($130.00 one year)
Concrete Haulers (4 Axles) ($130.00 one year)
Indicate permit type requested (check one):
REQUESTED EFFECTIVE DATE (mm/dd/yyyy)
Provide the requested permit effective date and duration below:
EXEMPT PERMIT DURATION
ONE YEAR TWO YEARS
Tank Wagon (2 Axles) -- ($130.00 one year)
Feed Hauler ($130.00 one year)
Boat/Watercraft ($130.00 one year)
Forest Products ($130.00 one year)
(Minimum 3 Axles) ($130.00 one year)
Hydro-excavating and Water Blasting Machinery (minimum 3
Axles) ($130.00 one year)
VEHICLE LICENSE PLATE NUMBER
ISSUING STATE
VIN / SERIAL NUMBER (last 5 digits)
VEHICLE INFORMATION
EXEMPT PERMIT INFORMATION
CERTIFICATION
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine,
and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under
penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
AUTHORIZED REPRESENTATIVE NAME (print)
DELIVERY (For current pricing, refer to Virginia hauling permit price list available on our website.)
DELIVERY (check one) (NOTE: For payment and delivery information please refer to the instructions on page 2 of this application.)
EMAIL (enter your email →)
USPS
FAX
AUTHORIZED REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
Purpose: Use this form to apply for an exempt hauling permit covering multiple
moves.
Instructions: Mail or fax this form to the address or fax number above. See page 2
for additional instructions.
VIRGINIA EXEMPT BLANKET
HAULING PERMIT APPLICATION
GOVERNMENT MOVE (check one)
CONTACT PERSON NAME
STATE
ID NUMBER (VAHPS ID, FEIN, OR SSN)
SHIPPER
Telephone: (804) 786-2787 ● Fax: (804) 367-1003
DMV USE ONLY
RECEIVED DATE (mm/dd/yyyy) REFERENCE NUMBER
CHECK NUMBER CHECK AMOUNT
Shipper Address ChangeNew Shipper Location
STATE LOCAL
FAX NUMBER
COMPANY NAME
MAILING ADDRESS
P. O. BOX, SUITE NUMBER (if applicable)
EMAIL ADDRESS
CITY ZIP CODE
VA JURISDICTION (county or city—VA only) COUNTRY
