Date Issued_______________ New Jersey Motor Vehicle Commission Expires___________________ Permit No._________________ For Office Use Only Application For Special Road Crossing Permit Section " A" The undersigned hereby makes application for permission, for operators of the vehicle(s) described in Section "B", to cross a public highway(s), at the location specified in this section. APPLICANT___________________________________________________________________________ STREET ADDRESS_____________________________________________________________________ CITY____________________________________STATE____________ZIP CODE___________________ LOCATION OF CROSSING_______________________________________________________________ ANTICIPATED FREQUENCY OF CROSSINGS_______________________________________________ WIDTH OF CROSSING ZONE_____________________________________________________________ RESTRICTIONS________________________________________________________________________ Insurance Company_______________________________Policy No.______________________________ The undersigned, certifies that, to the best of his knowledge and belief, that all information contained in this application is true and correct, that he is the legal owner of the affected property, or his authorized representative, and that the vehicle described in this permit will not damage the highway or present a hazard to the public traveling along such highway. I have read the regulations controlling the use of Highway Crossing Permits and agree to abide by them. I understand that the operator, permit holder, and vehicle owner shall be subject to the provisions of the Security Responsibility Law should an accident occur while on a public highway. Daytime Telephone Number (_____)_________________________ Signature of Applicant____________________________________ Date_______________________ Complete Section "B" (Attached) authorizing movement of the vehicles at the specified location in Section "A". GU-41A (R7/05) American LegalNet, Inc. www.FormsWorkFlow.com