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1 TYPE permit REQUESTED: Single Trip Single Trip & Return Annual Seasonal _____months Emergency Preliminary Superload Final Superload _____ of _____PERMIT OFFICE _____ NAME _____ACCOUNT NO. _____ STREET _____FEIN/SSN _____ CITY-STATE-ZIP CODE _____BILL CODE _____ permit FEE GROSS WEIGHT _____(lbs.) LEGAL WEIGHT _____(lbs.) TOTAL LENGTH _____(ft.) _____ (in.)TOTAL WIDTH _____ (ft.) _____ (in.) BODY WIDTH (63A/63B) _____(ft.) _____ (in.) TOTAL HEIGHT _____(ft.) _____ (in.)LOAD _____ _____ _____ _____VEHICLE # EQUIPMENT TYPE (List Power & Drawn Units)US DOT # PLATE#/VIN # STATE # AXLES123 TOTAL AXLE WEIGHTS _____AXLE DISTANCES (Ft.)

2 In.) _____ORIGIN: _____ _____ _____ DESTIN: _____ _____ _____ ROUTE NO(S): _____ TOTAL MILES _____DATE MOVE BEGINS _____ DATE MOVE ENDS_____APPLICANT WILLING TO ACCEPT ALTERNATE ROUTES? NO YES IF YES: _____ ADDITIONAL NAME _____ FAX permit TO _____Complete this section and attach a certificate of insurance if account number is not provided above [See 67 PA Code, (a) and (b)] Insurance Company _____ Agent Phone No. _____Policy No(s) _____ Effective Period(s) _____ providing:(a)Commonwealth is added as an additional insured for property damage and personal injury, and(b)

3 Insurance covers public liability and property damage in the amounts of at least $250,000 per person and at least $1,000,000 per have read the reverse of this form and hereby certify that the data submitted is correct to the best of my knowledge and belief, that the load is nondivisible, that satisfactory arrangements have been made with the proper authorities to travel all roads and cross over and under all structures not under the jurisdiction of the Department of Transportation, that required insurance will be in effect until permit expires and that the driver will be provided with a copy of both the issued permit and Department Form M-938.

4 QUANTITYOVERSIZE/OVERWEIGHTAPPLICATION FOR SPECIAL HAULING permit ''ALL LINES (EXCEPT DASHES) MUST BE COMPLETED"PREVIOUS permit NO.:APPLICATION ID:M-936A (11-17)REGISTERED NAME (Responsible Motor Carrier)ADDRESS1 = IMMEDIATE PAYMENT3 = MONTHLY BILLING4 = GOVERNMENTAL <LIST ANY INTERIM NON-STATE ROUTES IN PARENTHESESMOTOR CARRIER/ permit SERVICEIF NO MOTOR CARRIER ACCT. #CHECK/MO #<<<(1) SERIAL ID (LAST SIX DIGITS) (2) BOLTYPE CODELOAD DESCRIPTION - BE SPECIFIC(LBS.)COUNTYSTATE POINT OF INTEREST or MILES & DIRECTION FROM INTERSECTIONMUNICIPALITYCOUNTYSTATE POINT OF INTEREST or MILES & DIRECTION FROM INTERSECTIONMUNICIPALITYLIST EACH PROPOSED ROUTE AND DIRECTION OF TRAVEL ( , I-80E, I-81N)(WALK-IN APPLICANTS: LEAVE BLANK)(WALK-IN APPLICANTS: LEAVE BLANK)SIGNATURE OF APPLICANTDATE APPLIEDTIME APPLIEDPHONE ADDRESSF ront Axle2nd Axle3rd Axle4th Axle5th Axle6th Axle7th Axle8th Axle9th AxleNAME OF APPLICANT (PRINT)DEPARTMENT USE ONLYPERMIT RESTRICTIONS.

5 == OF APPEAL Applicants may appeal a denial of a permit by the Department under 2 PA Sections 501-508, 1 PA Code Part II and Chapter 491, by submitting a written request for a hearing within 30 days after service of the document containing the denial, to the Administrative Docket Clerk, Office of Chief Counsel, 400 North Street, 9th Floor, Harrisburg, Pennsylvania 17120-0096. A filing fee as prescribed under Chapter 491,made payable to the ''Commonwealth of Pennsylvania,'' shall accompany each FEESA pplication made in person or by mail shall be accompanied by a certified check or money order in the prescribed amount, however, company checks are acceptable from persons having a valid Account Number.

6 Applicants are encouraged to obtain an account number. General Issuance Fee (plus 4 cents per ton-mile for overweight) ..$36 (If < 14' in width) $75 (If > 14' in width) Mobile Home or Similar Oversize Trailer, Modular Unit or Undercarriage ..$41 (If < 14' in width) $80 (If > 14' in width) For other fees, see Chapter 19 of the Vehicle Code and Department Regulation In addition to the General Issuance Fee above, a ton-mile fee is assessed on all weight in excess of the registered gross weight. To compute this fee, fill in the correct amounts from the front of the application ( , Gross Weight, Legal Weight, Total Miles).

7 Gross Weight Legal Weight (-) Difference (=) Difference converted to WHOLE TONS (divided by 2000) (Always convert to the next highest whole ton) Total Distance (x) Ton-Mileage (=) at 4 cents per ton-mile (x) .04 Ton-Mile Fee (=) (''Legal Weight'' is the registered gross weight or legal gross weight, whichever is less.)Adams ..01 Allegheny ..05 Berks ..08 Bucks ..09 Butler ..10 Cambria ..11 Cameron ..12 Carbon.

8 13 Centre ..14 Chester ..15 Clarion ..16 Clearfield ..17 Clinton ..18 Columbia ..19 Crawford ..20 Monroe ..45 Montgomery ..46 Montour ..47 Northampton ..48 Northumberland ..49 Perry ..51 Potter ..52 Schuylkill ..55 Sullivan ..56 Susquehanna ..57 Tioga ..58 Union ..59 Venango ..60 Warren ..61 Washington ..62 Wayne ..63 Westmoreland ..64 Wyoming ..65 York ..66 Cumberland ..21 Dauphin ..22 Delaware ..23 Elk ..24 Erie ..25 Fayette ..26 Forest ..27 Franklin ..28 Fulton ..29 Greene ..30 Huntingdon ..31 Indiana ..32 Jefferson ..33 Juniata ..34 Lackawanna ..35 Lancaster ..38 Lehigh.

9 39 Luzerne ..40 Lycoming ..41 McKean ..42 Mercer ..43 Mifflin ..44 PENNSYLVANIA COUNTIES AND CODESFor current contact information for permit Offices, visit our website at: >Doing-Business>Permits>Hauling InformationCONTACTSENGINEERING DISTRICTSHOW TO COMPLETE GENERAL APPLICATION FORM M-936 ACompleting PA permit Application Form M-936 AFollowing are detailed instructions for completing a permit Application (Form M-936A). All fields underscored with solid lines must be completed. All fields underscored with dashed lines should be completed where applicable if information is known ( , from this guide or a recent similar permit ).

10 If any information is incomplete, inaccurate or inconsistent, the application will be denied, so be sure to review each application for completeness, accuracy and consistency before submitting it to permit NO.: Complete only if a previous permit was issued within the past 30 days and is similar (particularly the routing) to the application being ID: PennDOT will assign the Application ID upon processing of the application data. This number should be used to identify any application processed by the Department. TYPE permit REQUESTED: Indicate the type of permit being requested by checking each applicable box and completing each applicable OFFICE: 3-digit number ( , 070).