Kentucky Transportation Cabinet |
TC 96-15 |
Division of Motor Vehicle Licensing |
04/2011 |
APPLICATION FOR SPECIAL LICENSE PLATE
(Original form is to be retained by the Organization requesting special license plate.)
Please Print or Type:
INDIVIDUAL APPLICATION
Name: ________________________________________________
Address: ________________________________________________________________________________________
City: __________________________________ County: ______________________ Zip: _______________________
Pursuant to Kentucky Revised Statute (KRS) 186.164, I am applying for the following special license plate:
Second Chance @ Life/Donate Life Kentucky
As an individual applicant, you must submit this application to the non-profit organization’s contact person. Each application shall be accompanied by a check in the amount of $25.00 payable to the sponsoring group or organization.
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ORGANIZATION OR GROUP APPLICATION
Name: Second Chance at Life
Address: P.O. Box 21425
City: Louisville |
State: KY |
Zip: 40221-0425 |
As a sponsoring organization, you shall submit one (1) payment for the entire group of applicants. This check shall be made payable to the Kentucky State Treasurer.
A minimum of 900 applications for a special license plate must be received within two (2) consecutive calendar years from the original date of application or the plate will not be produced.
Original – Organization |
Copy – Customer |
