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Get Az Dot 96-0104 2018

PAIRED PLATE/PLACARD APPLICATION For eligibility and additional information see reverse side For replacements, use form # 40-0112, available online Plate Both I understand that by submitting this form I have read the front and back of this form and agree to take full responsibility for the use of the Disability Placard(s) or Plates that are issued to me. Name of person with disability (first, middle, last) please print Date of Birth Arizona ID or Driver License # Arizona Street.

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