Form Dmv-37-Tr - Application Form For A 60 Day Non-Resident Special Permit West Virginia
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1DMV-37-TR
REVISED 01/2014
West Virginia Department of Transportation
Division of Motor Vehicles
1-800-642-9066
Application for a 60 day Non-Resident Special Permit
A CURRENT REGISTRATION CARD AND $51.50 FEE MUST ACCOMPANY THIS APPLICATION.
A) Applicant/Owner(s) Information •
Applicant name must match the name on the registration card issued in the state of residence.
Applicant Name __________________________________________________________________________________________________
West Virginia Address _____________________________________________________________________________________________
State of Residence Address _________________________________________________________________________________________
B) Vehicle Information
B) Vehicle Information
Year
Title No.
Make
Plate Expiration Date
Current Plate No.
VIN No.
C) Insurance Information
/
/
/
/
E ective Dates of Policy From: _______________ To: _______________ Policy No. _________________________________________
Insurance Company _______________________________________________________________________________________________
NAIC Number __________________ Insurance Agent __________________________________________________________________
D) Employment Information
1.) Applicant Occupation _____________________________________________________________________________________________
2.) Is the Applicant Self Employed?
Yes
No
3.) Applicant Employer (If not self employed) ____________________________________________________________________________
4.) Nature of Applicant’s Work __________________________________________________________________________________________
5.) Applicant’s employment or business in West Virginia can be described as: (A)
Temporary, beginning on _____________________ and
ending on __________________; (B)
Recurrent, due to __________________________________________________ ; (C)
Seasonal,
due to, ________________________________________________________; or (D)
For the frequency of periods of such employment
or business _______________________________________________________________________________________________________.
6.) Name and Address of the Applicant’s Immediate Supervisor _______________________________________________________________
7.) Does the applicant plan to be self employed or employed by any other individual, company, or corporation sixty days from the date
of this application?
Yes
No If “yes”, name and address of the same ___________________________________________________
__________________________________________________________________________________________________________________
E ) Applicant Certi cation
I hereby state under penalty of false swearing, that the statements made herein are true and correct to the best of my knowledge and belief, and
understand that any false statements may result in legal penalties pursuant to West Virginia Motor Vehicle Law §17A-9-1; Fraudulent Applications.
(X)
/
/
(
)
Phone No.
DATE
SIGNATURE OF APPLICANT(S)
F ) Employer Certi cation • THIS SECTION IS REQUIRED IF THE APPLICANT IS NOT SELF EMPLOYED
I hereby state under penalty of false swearing, that the statements made herein are true and correct to the best of my knowledge and belief, and
understand that any false statements may result in legal penalties pursuant to West Virginia Motor Vehicle Law §17A-9-1; Fraudulent Applications.
(X)
(NAME OF APPLICANT’S EMPLOYER - INDIVIDUAL, COMPANY, OR CORPORATION)
SIGNATURE AND TITLE OF OFFICER
WV DMV USE ONLY
Date Received ________________
Date Approved ________________
Date Special Permit Expires ________________
Plate Number Issued _______________________________
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