Application for University of Wyoming Plates_201404091223439868

APPLICATION FOR UNIVERSITY OF WYOMING PLATES APPLICANT AND VEHICLE INFORMATION Owner(s) Name (Exactly As Shown On Title} Daytime Phone Number City Vehicle Make Year VIN Body Style Title # CURRENT PLATE INFORMATION County Where Vehicle is Registered State ZIP Current License Plate Number w/Expiration Date OPTIONAL - EMBOSSED (Additional fee of $50.00 payable to WYDOT) D I would like my plate embossed for an additional fee of $50.00 (THESE PLATES MAY TAKE 10-12 WEEKS FOR PROCESSING.) PLATE TYPE - $130.00 FEE PAYABLE TO THE UNIVERSITY OF WYOMING D University of Wyoming* *Completed application shall be mailed to the address shown at the bottom of this form, along with a fee of $130.00 made payable to the University of Wyoming ($100 fee for UW scholarships or student programs and $30 special plate fee) The application will be reviewed by the University and, if approved, forwarded to the Wyoming Department of Transportation Plates will be issued in consecutive order and forwarded to the County Treasurer's Office you have listed Current plates must be surrendered to the Treasurer's office upon issuance of the UW plates AFFIDAVIT I hereby swear or affirm under penalty of perjury that all information on this application is true and correct Signature of Applicant Date Approved (University of Wyoming Signature) Date APPLICANT SHALL MAIL THIS APPLICATION AND FEE PAYABLE TO THE UNIVERSITY OF WYOMING: University of Wyoming, Alumni Association, 214 South 14'" Street, Laramie, WY 82070 FOR ADDITIONAL INFORMATION PLEASE CALL: 307-777-4709 or visit our website at http://www.dot.state.wy.us FOR WYOMING DEPARTMENT OF TRANSPORTATION AND UNIVERSITY OF WYOMING USE ONLY Plate# Issued By Date MV-143 (9/12)