Registrant Identification No. (Driver's Licence No.) Name of Vehicle Owner, Dealer or Manufacturer Address Name of Lessee Lessee Address
Buyer is responsible to notify the ministry within six days of a change of ownership of this vehicle.
Laden Commercial Commercial with Trailer Auto Auction Out of Province / Out of Country Other Enter other here
Vehicle Type
1. All passenger vehicles (except buses) 2. All trailers (laden or unladen) 3. Unladen Commercial Motor Vehicle (includes a laden commercial motor vehicle where the gross weight of the commercial motor vehicle and any towed trailer does not exceed 4500 kilograms, EXCEPT where the commercial motor vehicle is a bus) 4. Laden Commercial Motor Vehicle (including buses) without a trailer (includes a laden commercial motor vehicle where the gross weight of the commercial motor vehicle exceeds 4500 kilograms, and any laden bus regardless of gross weight) 5. Commercial Motor Vehicle (including buses) towing a trailer (includes either or both of the vehicles being laden and where the gross weight exceeds 4500 kilograms, and any laden bus towing a trailer)
Make Year Prov./State V.I.N. (Serial No.)
It is an offence to apply for a Special Permit for a vehicle that is in an unfit status. The fee paid for a Special Permit is non-refundable.
Name (Please print) Authorized Signature Date
I hereby certify that the motor vehicle described above is insured under a contract of automobile insurance made with:
Name of Insurance Company Policy No. Name (Please print) Authorized Signature Date
It is a serious offence to make a false statement on this form.
Office No. Op.No. Issue Date Issue Time Permit No.
SSC Enter SSC SIC Enter SIC
Method of Payment Cash Cheque Debit Credit Card Other Enter Other
Fee $
Identification Viewed Personal Identification Third Party Type of Identification and Number
Information in this form is collected under the authority of the Highway Traffic Act, s. 205, and is used to evaluate the eligibility of the applicant to obtain the Special Permit. If you have any questions about the collection and use of your personal information collected on this form, please call the Supervisor, ServiceOntario, at 416 235-2999 or 1 800 387-3445 or write to the Supervisor, Ministry of Transportation, Licensing Administration Office, Main Floor, Building A, 1201 Wilson Ave., Downsview ON M3M 1J8. Direct general inquiries to ServiceOntario at 416 235-2999, 1 800 387-3445 or visit ServiceOntario.ca.