Virginia Blanket Hauling Permit Application Page 2
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3HP 401 (12/17/2015)
Page 2
ROUTE INFORMATION
CHECK ONE:
Specific route (Complete Section A below.)
All Unrestricted Routes (Skip to Certification Section)
I am STARTING at (check appropriate box):
State Line
/
/
County
City
City Name
State Abbreviation
County Name
My DIRECTION will be (check one):
on route
N
S
E
W
Provide additional starting point information ONLY if starting within Virginia.
miles
W of route
from starting address
The starting point is
N
S
E
I am ENDING at (check appropriate box):
State Line
/
/
County
City
City Name
State Abbreviation
County Name
My DIRECTION will be (check one):
on route
N
S
E
W
Provide additional ending point information ONLY if ending within Virginia.
miles
to ending address
W of route
The ending point is
N
S
E
ROUTE REQUESTED
PERMIT FEES
If overweight, an additional $40.00 mileage and $360.00 damage fee per year will apply. If the vehicle or
1 year — $100.00 (
the equipment being towed cannot be licensed in Virginia (i.e. Self-propelled crane, mobile home), a $40
mileage fee will apply.)
—
If overweight, an additional $40.00 mileage and $360.00 damage fee per year will apply. If the vehicle or
2 years
$200.00 (
the equipment being towed cannot be licensed in Virginia (i.e. Self-propelled crane, mobile home), a $40
mileage fee will apply.
)
CERTIFICATION
My signature below certifies that I understand no amendments will be made to a Virginia Hauling Permit once it is issued.
I further certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand
that knowingly making a false statement or representation on this form is a criminal violation.
AUTHORIZED REPRESENTATIVE SIGNATURE
AUTHORIZED REPRESENTATIVE NAME (print)
DATE (mm/dd/yyyy)
DELIVERY
(For current pricing, refer to Virginia hauling permit price list available on our website.)
DELIVERY (check one) (NOTE: For payment and delivery information please refer to the instructions on page 3 of this application.)
FAX
USPS
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