Fillable MANDATORY INSPECTION PROGRAM DECAL ORDER FORM (Minnesota)
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MANDATORY INSPECTION PROGRAM DECAL ORDER FORM (Minnesota)
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Minnesot a Depar tment o f Public S afety – State Patrol Division
MANDATORY I NSPECTIO N PROGRA M DEC AL ORDER FORM
Fill out i nformation to the r ight.
Pleas e type or pr int y our
nam e and m ailing
address l egibly. Please provide unattached
return label(s).
Company Telephone Number
Company Name
Mailing Addres s
City State Zip Code
Decals are available for the current year and one preceding year. Decals for the follow ing
year will be available beginning December 1 . Decals are not refundable or
exchangeable. Please order carefully. Dec als are $2.00 each.
W hat year decal s do you w ant t o purc hase?
H ow ma n y decals do you w ant to purchas e?
Total due for decals $ ( Do not include credit c ard fee.)
Make check p ayable t o STATE O F MINNESOTA . (Please do not attach check stub or staple to orders)
Mail order form and remittance to: MN State Patrol Commercial Vehi cle Section
1110 Centre Pointe Curve #410
Mendota Heights, MN 55120
If y o u h av e a ny ques t ions a bout t he dec al or d er, pl eas e cal l t he M innesot a Sta t e Patro l at ( 651)350 - 2000.
Credit Card Orders : F or your s ecurity, w e do not accept c redit c ard orders b y e -m ail or f ax. P lease mail your or der t o t he above
address. A s ervice charge of $4. 50 is as sessed for ea ch credit c ar d order. On Orders for multiple inspectors - the card number
only needs to be entered on the top form.
Credit Card Number Month/ Year
It is her eby agreed this insp ector w ill recogni ze the critical c riteria establishe d by the State Patrol Di visio n of the Departm ent of
Public Safet y, and shall pla ce decals onl y upon vehicle s that h ave pas sed ins pection as prov ided b y law.
Should it ever be determ ined th is insp ector has issued decals without r egard t o all provis ions s et forth in 49 C FR 396. 17 and
MS 169.781 , the pr ivile ges of perf orming cer tified ins pections m ay be revoked.
Decals listed bel ow are to be us ed onl y by the inspector who has signed this form . Use by an y other person is strictl y prohibited .
