Contact Information
Applicant/Company Name:
Contact Person:
Address:
Email:
Phone:
Cell:
Transport Information
Start date:
End date:
Start time:
End time:
Commodity being transported:
Axel weight (total load): ______ kg
No. of tires: ______
Axel spacing: ______ cm
Overall width: ______ m
GVW: ______ kg
Size of tires: ______
Axel spacing: ______ cm
Overall width: ______ m
Front overhang: ______ cm
Rear overhang: ______ cm Axel spacing: ______ cm
Overall width: ______ m
Tractor MV License:
Jurisdiction:
MV Registration No.:
Trailer License No.:
Insurance Policy No.:
Value:
Equipment Used
 Beacons
 Signs – Front
 Signs – Rear
 Lights/Floodlights
 Pilot Car(s)  Flags
 Yes, our operator has driven the route and confirms that there are no conflicts (Examples: overhead wires,
traffic signals, street lights, traffic signs, roadside barriers centre medians, bridge or sidewalk railings, etc)
Applicant’s Signature:
Date: