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2. Electronic Signature Agreement*

   By checking the "I agree" box below, I understand I need to allow a minimum of 3 business days to process this application form.

   1. I agree.
4. Name of Organization*
6. Address for Organization*
8. City*
9. State*
10. Zip Code*
12. Name of Applicant*
13. Email Address (This is the e-mail address the certificate of registration will be e-mailed to*
15. Address of Residence for Applicant*

    If you have lived at another residence in the last five years, please fill in the additional addresses and dates in the box below. If it does not apply, enter N/A,

17. City*
18. State*
19. Zip Code*
21. Additional Addresses with Dates*
    If this does not apply, enter N/A,
23. Phone Number*
25. Start and End Dates *
    Start and End Dates Start Date

    —

    Start and End Dates End Date

    This permit will be issued for a period of up to one year. 

27. Describe the nature of business/orders to be taken,*
29. Description of vehicle:*
    (Year, make, model, color, plate number)
31. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
33. Electronic Signature
35. Acknowledgement - No Fee*

    1. By clicking here, I understand the following:

    This application can take up to seven (7) business days to process (sometimes longer). 

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field