Mandatory Inspection Program Decal Order Form
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1Minnesota Department of Public Safety – State Patrol Division
MANDATORY INSPECTION PROGRAM DECAL ORDER FORM
Fill out information to the right.
___________________________________________
Company Name
Please type or print your name and
mailing address legibly. It will be
___________________________________________
used as your return label.
Mailing Address
______________________________
___________________________________________
Company Telephone Number
City
State
Zip Code
2016 DECALS
For Vehicles inspected in 2016
How many decals would you like to order? ________________
Decals are not refundable or exchangeable; please order carefully.
Please enclose $2.00 per decal ordered. We cannot accept purchase orders. Make check or money order payable to:
STATE OF MINNESOTA.
Return order form and remittance to:
TOTAL AMOUNT DUE FOR DECALS: $ _________________________
MN State Patrol, CMV Section
Any questions about the decal order, please call the MN State Patrol Office
1110 Centre Pointe Curve, #410
(651) 405-6173.
Mendota Heights, MN 55120
Credit Card Orders:
You may scan and e-mail your orders to
PATROL.MIPDECALSALES @STATE.MN.US
including inspector numbers in subject
line. Scanned orders must include credit card number and expiration month and year. A service charge ($4.50) is assessed for
credit card orders. PLEASE DO NOT FAX.
________________________________________________________________________
_____________________
Credit Card Number
Month/Year
•
It is hereby agreed that this inspector will recognize the critical criteria established by the State Patrol Division of the
Department of Public Safety, and shall place decals only upon vehicles which have passed the inspection as provided by law.
•
Should it ever be determined that this inspector has issued decals without regard to all provisions set forth in 49 CFR 396.17
and M.S. 169.781, the privileges of performing certified inspections may be revoked.
•
Decals listed below are to be used only by the inspector who has signed this form. Use by any other person is strictly
prohibited.
Agreed by:
_________________________________________________
________________________________________________
Certified Inspector’s Signature
Date
Inspector Certification Number
_________________________________________________
________________________________________________
Print Inspector Name
Company Name
For Office Use Only
Beginning Decal # ______________________________
Ending Decal # ______________________________
201
Transaction Type________________ Check # ________________________ Date Issued________/________/
___ Issued by:___________________
(Revised 10/27/2015)
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