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M-936A (11-17). OVERSIZE/OVERWEIGHT PREVIOUS. APPLICATION FOR SPECIAL permit NO.: HAULING permit . ''ALL LINES (EXCEPT DASHES) MUST BE COMPLETED" APPLICATION ID: TYPE permit REQUESTED: Single Trip Single Trip & Return Annual Seasonal ________months Emergency Preliminary Superload Final Superload _______ of _______. permit OFFICE_________________________________ NAME____________________________________ _____________________________________. REGISTERED NAME (Responsible Motor Carrier). ACCOUNT STREET__________________________________ _____________________________________. MOTOR CARRIER/ permit SERVICE ADDRESS. FEIN/SSN________________________________ ______ CITY-STATE-ZIP CODE____________________________________ _______________________. IF NO MOTOR CARRIER ACCT. NO. 1 = IMMEDIATE PAYMENT. 3 = MONTHLY BILLING. BILL CODE____________________________________ 4 = GOVERNMENTAL CHECK/MO # CHECK/MO #.

PERMIT FEE: The Permit Fee will be determined at the time of issuance. The permit fee is the sum of the issuance fee and any ton-mile, escort or other established fees (e.g., $1 wire fee). See reverse of Form M-936A for the formula used to compute ton-mile fees.

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