Transcription of N D REQUIREMENTS ChECK ( ) APPROPRIATE …
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Example: air traffic controller
N D REQUIREMENTS ChECK ( ) APPROPRIATE …
ORIGINAL request - permanent placard Severely Disabled Veteran temporary placard renewal request - ( for permanent placards only )REPLACEMENT request - placard ID CARD Defaced Lost Stolen Never Received PREVIOUS placard # _____ChANGE OF ADDRESS - Complete Sections A and : Notarization is not OF NAME - Complete Sections A and here to indicate reason for change of name: Marriage Divorce Other: _____qqqqqChECK ( 4 ) APPROPRIATE bLOCKS bELOWqqAAPPLICANT INFORMATION - LIST NAME AND ADDRESS OF PERSON WITh DISAbILITY - NOTE: If listingan out-of-state address, you must also complete and attach Form FROM A hEALTh CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A CONTIGUOUS STATE (NEW YORK, NEW JERSEY, DELAWARE, MARYLAND, WEST VIRGINIA OROhIO).
ORIGINAL REQUEST - Permanent Placard Severely Disabled Veteran Temporary Placard RENEWAL REQUEST - (For Permanent Placards Only) REPLACEMENT REQUEST - PLACARD ID CARD Defaced Lost Stolen Never Received PREVIOUS PLACARD # _____
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