One per vehicle

All information must be completed in full!



Unit Number:______ Vehicle ID #:______________________________________


Year: ______ Make:__________  Model:_________________________________


Gross Vehicle Weight (GVW):_____________ Empty Weight:_________________


Number Of Axles: _________


What type of vehicle is this? (Circle One)  TT, TK, PW, or BUS

         (TT-Truck Tractor, TK-Straight Truck, PW-Wrecker)


(A)      Do you pull a trailer? _____Yes  _____ No

(B)      Type of fuel _________________________


State truck is base plated in ______________________


Plate # _____________________________________

Is this an Apportioned plate?          _____Yes _____ No

If yes, what is you IRP account number? _________________