OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES PERMIT AGENCY APPLICATION FOR OHIO 72 HOUR TRIP PERMITS DATE (MM/DD/YY) PLEASE TYPE OR PRINT LEGIBLY AGENT’S NAME AGENT’S NUMBER BUSINESS ADDRESS CITY STATE ZIP NOTE: 72 HOUR TRIP PERMITS ARE SOLD IN BLOCKS OF TWENTY-FIVE (25) PERMITS TO TRIP PERMIT AGENTS. MINIMUM ORDER IS 25 PERMITS. PLEASE SEND QTY 25 50 75 100 @ @ @ @ @ PRICE 15.00 15.00 15.00 15.00 72 – HOUR TRIP PERMITS, BMV 5765 = = = = = TOTAL $ 375.00 $ 750.00 $ 1,125.00 $ 1,500.00 I HAVE ENCLOSED PAYMENTS IN THE AMOUNT OF $ FOR THIS ORDER, AND HEREBY CERTIFY THAT ALL PERMITS RECEIVED WILL BE USED IN ACCORDANCE WITH THE STATUTES, RULES, AND REGULATIONS OF OHIO. SIGNATURE OF AGENT/AGENT’S REPRESENTATIVE DATE (MM/DD/YY) X FOR DEPARTMENTAL USE ONLY (AGENT, DO NOT WRITE HERE) FROM Permit Numbers Issued Agent Number Verified? Yes No TO Paid By EQUALS Cash Check Money Order MAIL TO: OHIO BUREAU OF MOTOR VEHICLES ATTN: IRP TRIP PERMITS COORDINATOR P.O. BOX 16521 COLUMBUS, OH 43216-6521 BMV 5765 11/09 American LegalNet, Inc. www.FormsWorkFlow.com