Name of Registrant
Make
Model
Year
Serial Number

Please Select One:
Owner occupant 65 years of age or older. - Date of Birth
Owner totally disabled.
Soldier’s & Sailor’s Relief Act (Non-resident military).
Charitable subjects covered under Section 40-9-12 & 13 or Otherwise exempt.

Name of School, Association or Church / (If applicable)

Address of Registrant: