Form M-233dr - Annual Mobile Home Rig Dealer'S Permit Application
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1
2FORM M-233DR
Indiana Department of Revenue
Starting Date:
January 1
Expiration Date: December 31
State Form 49061
Annual Mobile Home
(R5 / 7-11)
Fee:
$40.00
Rig Dealer's Permit Application
Name of Transporting Company:
FEIN:
Address:
SSN: (if sole proprietor)
City, State, and Zip:
Make of Tractor:
Tractor Year:
Daytime Telephone:
Fax Number:
License State:
Plate Number:
Vehicle Type:
Full Vehicle Identifi cation Number:
Dealer's License Number:
(As issued by the Bureau of Motor Vehicles)
Overall Length: Up to 85'
Overall Width: 8'6" up to 12'4" wide
Overall Height: Legal
Total Gross Weight: Legal
Type of Permit: over 8'6" up to 12'4" Mobile Home Rig Dealer
This TRACTOR MOBILE HOME RIG exceeds the legal size and weight limits and cannot be reduced by method of
disassembly. This permit provides for transportation via all State and Interstate Highways offi cially opened to traffi c
except I-65 and I-70 inside I-465.
No other routes, including detours, are authorized by this permit under any condition.
The General Provisions on the reverse side of this form and any Special Provisions are incorporated by reference into
this permit and are as fully binding upon the permittee as if they had appeared on the face of this permit. This permit is
void or invalid if the General Provisions and Special Provisions are omitted from the reverse side of this form or are not
attached. The Indiana Department of Revenue disclaims any responsibility in relation to the correctness in the transmit-
ting of the permit as a whole or any part thereof, including general or special provisions.
This permit is valid only for transporting commodities under the company name shown above, and if signed by both an
authorized company owner or offi cer, and driver. The driver's signature attests to the fact that the description of the ve-
hicle and load is accurate and that the General Provisions and any Special Provisions have been read and understood
by the driver. Under the penalty of perjury, I have examined this permit, and to the best of my knowledge and belief, it
is true, complete and correct. I also understand that all provisions of the Transporting Agreement apply in full force.
Driver's Signature(s):
Date(s):
____________________________________________
____________________________________________
____________________________________________
____________________________________________
__________________________________________
____________________________________________
Company Owner or Responsible Offi cer
Date
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