OREGON WEIGHT-MILE TAX ENROLLMENT APPLICATION …

1 DO NOT WRITE IN SPACE ABOVEOREGON WEIGHT RECEIPT AND TAX IDENTIFIER APPLICATION (SEE INSTRUCTIONS ON REVERSE)DO NOT WRITE IN SPACE BELOWEFFECTIVE DATEPROOFED DATEPROOFED BYDATE KEYEDKEYED BYFEESRECEIPTREINSTATEMENTSUSPENSION459 TOTAL PAIDMLGFM12 FORM 735-9076 (1-18)CERTIFICATION: I HEREBY CERTIFY THAT THE STATEMENTS CONTAINED IN THIS APPLICATION ARE TRUE AND CORRECT; NO MATERIAL FACT HAS BEEN OMITTED; THERE IS NOT A PERSON HAVING ANY INTEREST, DIRECTLY OR INDIRECTLY, IN THE OWNERSHIP OF THIS OPERATION EXCEPT AS SPECIFIED ABOVE; AND THAT THE OWNERSHIP AS DESIGNATED WILL AT ALL TIMES HAVE FULL POSSESSION AND CONTROL OF ALL MOTOR VEHICLES OPERATED OR REGISTERED UNDER THIS NAMEDATETITLEOWNEDLEASEDSOLOAXLCOMB #4 AXLCOMB #3 AXLCOMB #2 AXLCOMB #1 AXLHUBKMREASON FOR APPLICATIONADD VEHICLERENEW VEHICLEAMEND VEHICLE (LIST VARIABLE BEING AMENDED) OREGON DEPARTMENT OF TRANSPORTATIONMOTOR CARRIER TRANSPORTATION DIVISION 3930 FAIRVIEW INDUSTRIAL DRIVE SE SALEM OR 97302-1166 PH (503) 378-6699 FAX (503)

2 378-6880 ACCOUNT NUMBERSUBBUSINESS NAMEEFFECTIVE DATETELEPHONE NUMBERFAX NUMBERADDRESSCITYSTATEZIP CODEINCLUDE A FAX NUMBER TO RECEIVE THE WEIGHT RECEIPT(S) VIA FAX. ALL CORRESPONDENCE REGARDING THE WEIGHT RECEIPT(S) WILL BE MAILED TO THE MAILING ADDRESS ON LICENSE NOLESSORODO READINGST/PROVYEARMAKECOMPLETE VEHICLE IDENTIFICATION NUMBERFUELUNIT NUMBERVTFEE BASISBDCANCEL VEHICLEOWNEDLEASEDSOLOAXLCOMB #4 AXLCOMB #3 AXLCOMB #2 AXLCOMB #1 AXLHUBKMREASON FOR APPLICATIONADD VEHICLERENEW VEHICLEAMEND VEHICLE (LIST VARIABLE BEING AMENDED)BASE LICENSE NOLESSORODO READINGST/PROVYEARMAKECOMPLETE VEHICLE IDENTIFICATION NUMBERFUELUNIT NUMBERVTFEE BASISBDCANCEL VEHICLEOWNEDLEASEDSOLOAXLCOMB #4 AXLCOMB #3 AXLCOMB #2 AXLCOMB #1 AXLHUBKMREASON FOR APPLICATIONADD VEHICLERENEW VEHICLEAMEND VEHICLE (LIST VARIABLE BEING AMENDED)BASE LICENSE NOLESSORODO READINGST/PROVYEARMAKECOMPLETE VEHICLE IDENTIFICATION NUMBERFUELUNIT NUMBERVTFEE BASISBDCANCEL VEHICLEOWNEDLEASEDSOLOAXLCOMB #4 AXLCOMB #3 AXLCOMB #2 AXLCOMB #1 AXLHUBKMREASON FOR APPLICATIONADD VEHICLERENEW VEHICLEAMEND VEHICLE (LIST VARIABLE BEING AMENDED)

3 BASE LICENSE NOLESSORODO READINGST/PROVYEARMAKECOMPLETE VEHICLE IDENTIFICATION NUMBERFUELUNIT NUMBERVTFEE BASISBDCANCEL VEHICLEIn order for each power unit to be registered correctly, carriers are required to provide all information requested on this form. PLEASE TYPE OR WRITE CLEARLY. Please provide the COMPLETE vehicle identification number. The codes listed below must be used when indicating vehicle body style, fuel type and fee basis. A fillable version of this form (ready to be completed on-screen and printed on a local printer) is available on the internet at: NOTE: It is essential that the license plate and the jurisdiction from which it is issued match the plate and the jurisdiction listed on the Weight Receipt that is issued from this APPLICATION .

4 Applications that are illegible, incomplete or incorrect may result in errors on the Weight Receipt(s) issued. Errors on Weight Receipts may subject a driver to citation and a $435 Receipts are valid when license plate noted on the Receipt is attached to the vehicle. If a license plate has not yet been placed on a vehicle and the vehicle will operate in OREGON , ODOT can issue a Temporary Weight Receipt. To obtain a Temporary Weight Receipt, write Issue Temp in the Base License No box. After a license plate has been issued and placed on the vehicle, you must contact ODOT to obtain a permanent Weight Receipt. The Temporary Weight Receipt is not valid if the vehicle is displaying a license your ACCOUNT NUMBER, BUSINESS NAME, TELEPHONE NUMBER and complete ADDRESS.

5 If you wish to have the Weight Receipts faxed back to you, include your fax number. If you do not have a file number, this form must be accompanied by an APPLICATION FOR MOTOR CARRIER PERMIT, ODOT FORM more than four vehicles, please use CONTINUATION SHEET, ODOT FORM 735-9076A or you may attach a list that follows the same format and includes the same information. Failure to do so may delay your REGISTRATIONADDITIONAL INFORMATION MAY BE REQUESTED IN WRITING OR BY CALLING (503-378-6699) OR VISITING:Your DECLARED WEIGHTS are subject to audit and approval by ODOT. If your combined weight is in excess of 80,000 lbs., you must obtain an OREGON Over Dimensional - The maximum loaded weight of a single unit (truck) or the weight allowable for a power unit operating with the trailer up (decked).

6 The MINIMUM allowable solo weight (decked) is the declared weight of the combination minus the maximum weight upon the trailer - The weight of the vehicle plus the weight of the maximum load the vehicle will transport. You must declare more than one combination if you operate different WEIGHTSSIGNATUREThe APPLICATION must be signed by the owner, partner, corporate officer or manager/member of an MUST ACCOMPANY THIS APPLICATIONFor each of the listed transactions a fee will each registered vehicle which is to be corrected, enter the BASE PLATE NUMBER, check the "AMEND VEHICLE" box and list the item being a weight declaration is to be changed, list ALL weight declarations under which the vehicle is to be registered for future form may be used to renew a Weight Receipt for the following year.

7 Enter the Base License No you want renewed and check the RENEW VEHICLE AMENDMENTThis form is to be completed and filed when applying for: 1) OREGON Weight Receipt and Tax Identifiers for new vehicles; 2) Amended Weight Receipt for vehicle already on file with ODOT; 3) Renewed Weight Receipt and Tax Identifier. FEE BASIS CODES1 - MONTHLY MILEAGE2 - FLAT MONTHLY4 - QUARTERLY MILEAGE5 - ANNUAL MILEAGEIF NOT LISTED, USE FIRST FOUR LETTERS OF a combination vehicle, the type of trailer is the body style.*M - MIXERR - VEHICLE CARRIERS - LIVESTOCK TRUCKT - TANKV - VANWB - WRECKER CLASS BWD - WRECKER CLASS DWC - WRECKER CLASS CX - FIXED LOAD, BOOM, CRANE, WELL DRILLER, GRADER.

8 ETC Z - OTHERC - CHIP TRUCKD - DUMP TRUCKF - FLATBEDG - GARBAGE TRUCKH - MOBILE HOME TOTERK - SELF-LOADIING LOGGERL - SHORT LOGGER OR MULE TRAIN 1L - LONG LOGGERBODY STYLE*CODESMAKE ABBREVIATIONSAUTCCHEVDIATDODGENISSSTRGWE STWHGMFORDFRGHGMCHINOINTLKWMACKFUEL CODESD - DIESELG - GASOLINEP - PROPANEA - A55H - GASOHOLY - ELECTRICX - HYBRIDB - BIODIESELL - LIQUID NATURAL GASC - COMPRESSED NATURAL GAS5 - M85M - METHANOL8 - E85E - ETHANOLW eight Receipt and Tax IdentifierTemporary Weight Receipt and Tax Identifier (to be issued when license plate is not yet on vehicle) Weight Receipt and Tax ldentifier issued after a license plate is placed on a vehicle with a Temporary Weight ReceiptAmended Weight Receipt or Temporary Weight ReceiptRenewed Weight Receipt or Temporary Weight ReceiptY - LOWBOYNOTE: You must report the OREGON Highway Use Tax for the operations of all vehicles with OREGON Weight Receipt under your account, including leased - DUMP TRUCKHF - HEAVY FIXEDMT - MOBILE HOME TOTER TK - TRUCKTR - TRACTORTT - TRUCK & TRAILER TW - TOW VEHICLEVEHICLE TYPESMCIVANTMCPREVBS - PASSENGER BUSBA - BUS ARTICULATEDB - BUS