ol%AtffiHftiil'ffi'm;"
vR-124(5-05)
Instructions:pleasecompletethe entireapplication(ownerand/orco-owner).Submitappropriatefeeswith application (see reverse,lower right corner)
x-ameof o-rsai t ceitity that the individualbelow is a bona fide memberof the aboveorganization: I Signatureof AuthorizedRepresentative Owner'sName, First
Co-Owner'sName,First
Number License Driver's
Last
Middle
Zip Code
State
County
City
StreetAddress
Driver'sLicenseNumber
LaSt
Middle
I hereby authorize the representativeof my organization to reviedrelease my personal information for official purposesl
Signature Co-Owner's
t Owner'sSignature VehicleInformation Make Year
StickerNo.
Tag No.
Title No.
VehicleldentificationNumber No. Policy/Binder
Co. lnsurance
D Co-Owner E Owner OrganizationalMember: (Checkone) E 1 ton or less vehicle Q Vtutti-purpose Check Class: D PassengerCar Logo: $25.00 Fees: Non Logo OrganizationalTags:$15.00
E Motorcycle
I certify,underpenaltyof perjury,that the aboveinformationis true and correctto the bestof my knowledge:
of Owner I Signature
Date
Signatureof Co-Owner
Date
MVA Use Only: D New lssue E Substitute D SurvivingSpouse E Slttl
Taglssued:
O Gratis E Paio Approvedby:
You may eithermail your applicationand the appropriatefees to: Unit;6601 RitchieHighway,Glen Burnie,MD 21062; Organizational VehicleRegistration Administration, MotorVbhicle plates your issuedto you. have and in Burnie Glen Office full Service MVA or visit the
Oilginal - MVA
Copy - Customer
(1682)(to speak with a customerservicerepresentative)' (touchtone calls only),1-800-950-1MVA Fo, rore information,pleasecall:1-800-638-8347 Visit our websiteat: www-marylandmva'com TTY for the hearingimpaired:1-800-492-4575. From Oufof-State:1-301-729-4550,