Company: _____________________________________________________________________

Address: ______________________________________________________________________

City: _________________________ State: ________________ Zip Code: ______________

Telephone: ( _____ ) ______-________ Representative of Company: ____________________

Federal Employee Identification Number (FEIN): _____________________________________

Social Security Number if no FEIN number: _________________________________________

PROVISIONS

     The Company will deposit with the Kansas Department of Revenue (KDOR), Central Permit, a minimum of $100 in an escrow account and allow Central Permit and/or the Kansas Department of Transportation (KDOT), Central Permit, to draw funds from this account to pay for permit issued by them. An account number will be assigned to the Company. Each time a permit is issued the fee will be deducted from the escrow account. If the escrow account reaches a zero balance, further permits will not be issued until the escrow account is replenished. In no case shall the balance in said account fall below a zero balance.

    The above named Company absolves, agrees to defend and holds harmless the Kansas Department of Revenue and/or the Kansas Department of Transportation of any liability relating to the issuance of the escrow account.

I further understand, the escrow account may be canceled at any time at the discretion of Central Permit.

Company Signature:

___________________________________________________   Date:____________________
(Authorized Signature)

Approved by:

___________________________________________________   Date:____________________
(Administrator Central Permit)