1275 - Reset Form MISSOURI DEPARTMENT OF REVENUE MOTOR...

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MISSOURI DEPARTMENT OF REVENUE MOTOR VEHICLE BUREAU PO BOX 100, JEFFERSON CITY, MO 65105-0100 (573) 526-3669 www.dor.mo.gov/mvdl SPECIAL PERMITS APPLICATION MO 860-0265 (8-2009) DOR-1275 (8-2009) SEE REVERSE SIDE FOR INSTRUCTIONS AND LIMITATIONS VALIDATION ONLY APPLICANT’S NAME DLN/FEIN NUMBER STREET ADDRESS OR R.F.D. COUNTY CITY, STATE, ZIP CODE TELEPHONE NUMBER IF APPLICANT IS A DEALER, SHOW DEALER LICENSE NUMBER HERE: Enter the amount and type of permit desired. USE A SEPARATE APPLICATION FOR EACH TYPE OF PERMIT UNLESS ORDERING BOOKS OF PERMITS. Proof of ownership must be submitted for each permit requested (except books of permits). A safety inspection must be submitted if obtaining a temporary permit on a motor vehicle. YEAR MAKE BODY STYLE VEHICLE IDENTIFICATION NUMBER No. of Items Required Permit Type Price (includes $3.50 processing fee) Amount Driveaway Permits @ $ 7.50 per set $ Maintenance Permits @ $ 8.50 each $ Temporary Permits @ $11.00 per set or $ $78.50 per book of 10 DocumentedVesselTemp.Permit @ $ 8.50 per set or $ $53.50 per book of 10 Temporary Watercraft Permit @ $ 8.50 per set or $ $53.50 per book of 10 Temp.Outboard Motor Permit @ $ 5.50 per set or $ $23.50 per book of 10 I HEREBY CERTIFY THAT THE INFORMATION GIVEN HEREIN IS TRUE AND COMPLETE AND THAT THE PERMIT(S) APPLIED FOR WILL BE USED IN ACCORDANCE WITH THE STATUTES OF MISSOURI. THE SIGNATURE BELOW SHALL CERTIFY THAT I HAVE AND WILL MAINTAIN DURING THE USE OF THIS PERMIT AND, PERIOD OF REGISTRATION, FINANCIAL RESPONSIBILITY WITH RESPECT TO EACH MOTOR VEHICLE THAT I OWN, LICENSE, OR OPERATE ON THE STREETS OR HIGHWAYS. ANY FALSE AFFIDAVIT IS A CRIME UNDER SECTION 575.050 OF MISSOURI LAW.
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