Transcription of Missouri State Humane Association STATEMENT …
1 CONTRIBUTION AMOUNT*: $PAYMENT DATE:AUTHORIZED SIGNATURE:*NOTE: The minimum contribution for a single year registration is $ The minimum contribution for a biennial registration is $ AUTHORIZATION STATEMENTDUPLICATE AUTHORIZATION STATEMENTM issouri State Humane AssociationEmbEmbEmbEmbEmblem Use Authorizalem Use Authorizalem Use Authorizalem Use Authorizalem Use Authorization Station Station Station Station StatementtementtementtementtementSTATEME NT NUMBER (OPTIONAL):ORGANIZATION CONTACT INFORMATIONAPPLICANT INFORMATIONNAME (LAST, FIRST, MIDDLE):MAILING ADDRESS:CITY: State :ZIP:TELEPHONE NUMBER (S)E-MAIL ADDRESS:CONTRIBUTION INFORMATIONDOR USE ONLY ANNUAL INITIAL REGISTRATION:INITIAL PLATE PICK-UP, BIENNIAL REGISTRATION:Q: What is an Emblem Use Authorization STATEMENT ?A: When a vehicle owner wants to obtain a specialty license plate from theMissouri Department of Revenue, the application must include an originalEmblem Use Authorization STATEMENT issued by the organization shownon the specialty license plate.
2 A copy is not Emblem Use Authorization STATEMENT is provided to the vehicle ownerafter he/she makes the designated minimum contribution to the organiza-tion for that purpose. An Emblem Use Authorization STATEMENT may beobtained for a one year or biennial process must be repeated every time the specialty license plateregistration is Box 21626St. Louis, MO 63109-0626
