Date: _________________
Full Name: ____________________________________
Owner/Lessee (Circle One)
(Name on Vehicle Registration of Owner)
Address: ___________________________________________
Residence/Business (Circle One)
Daytime Telephone No: ________________________________
Vehicle(s) for which decals are desired:
Year Make License Plate # Fee @ $30.00
1. ____ __________ _____________ ____________
2. ____ __________ _____________ ____________
3. ____ __________ _____________ ____________
4. ____ __________ _____________ ____________
Total ________
Make checks payable to the "City of Charlotte"
_________________________________________________
DO NOT COMPLETE - FOR OFFICIAL USE ONLY
PERMIT # ________________
Date Received: ______________
(Circle One)
1. MODE
a. Mail
b. Person
2. MV registration(s) attached? Yes, if No, go to #4; otherwise #3 (Circle One)
3. Address(es) within the permit area? Yes No (Circle One)
4. Other Identification: Name same as above: Yes No (Circle One)
Operator's License No. _____________________
Address ____________________________________________
Utility Bill: Description __________________________________
Address ____________________________________________
Legal Document: Description ____________________________
Address ____________________________________________
Paycheck: Employer ___________________________________
Address ____________________________________________
Other: Description ____________________________________
Address ____________________________________________
5. Date Rejected: __________________ Reason: ___________________________________________________
6. Date Permit Mailed: ______________ Area # _____________
Initials of Clerk: ________________________
