SELF-CERTIFICATION OF VEHICLE(S) TO BE OPERATED OR …
Interlock Vendor with my vehicle record for the purpose of processing this form. _____ _____ SIGNATURE IN INK DATE WARNING: Misstatement of facts is a misdemeanor of the third degree punishable by fine of up to $2,500.00 and/or imprisonment up to one year (18 Pa. C.S. Section 4904(b)) C E SELF-CERTIFICATION OF VEHICLE(S) TO BE OPERATED OR ...
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