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Application for Exemption for Certain Ambulance-Type Motor Vehicles

Name
Address
City
State
Zip Code
Vehicle Year, Make, and Model
Vehicle Identification Number (VIN)
Date of Registration
Date of Registration
Purpose of Transportation
Modifications to Motor Vehicle
Copy of invoice(s) and/or specifications must be attached.
Invoice(s)/Specifications
I hereby swear that the statements herein are true to the best of my knowledge and belief:
e-Signature
Date
Date

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