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Application for Retired Volunteer

Application for Retired Volunteer PO Box 1652, Halifax, Nova Scotia B3J 2Z3 Firefighter Plates or Retired Ground Search and Rescue Plates PLEASE PRINT ALL INFORMATION IN BLOCK LETTERS Phone 902 424-5851 Toll Free 1 800 898-7668. SECTION 1 Applicant Identification Name of Applicant Applicant Master Number Residence Address Mailing Address Postal Code Postal Code SECTION 2 Vehicle Information VIN / Serial Number Year Make Model Body Type Registered Weight SECTION 3 Plate Information Current / Previous Plate Prov / State Attach Plate Number Retired Volunteer Firefighter Retired Ground Search and Rescue NOTE: Applicant must be the registered owner of the vehicle or have written authorization from the vehicle owner.

NOTE: For purposes of this application a “retired volunteer member” means a person who: was a member of a Volunteer Fire Department or Ground Search and Rescue Organization for 15 years and while active participated in a minimum of 20% of calls and training. Form APP46 2004D(Rev. 09/15)

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Transcription of Application for Retired Volunteer

1 Application for Retired Volunteer PO Box 1652, Halifax, Nova Scotia B3J 2Z3 Firefighter Plates or Retired Ground Search and Rescue Plates PLEASE PRINT ALL INFORMATION IN BLOCK LETTERS Phone 902 424-5851 Toll Free 1 800 898-7668. SECTION 1 Applicant Identification Name of Applicant Applicant Master Number Residence Address Mailing Address Postal Code Postal Code SECTION 2 Vehicle Information VIN / Serial Number Year Make Model Body Type Registered Weight SECTION 3 Plate Information Current / Previous Plate Prov / State Attach Plate Number Retired Volunteer Firefighter Retired Ground Search and Rescue NOTE: Applicant must be the registered owner of the vehicle or have written authorization from the vehicle owner.

2 I HEREBY ACKNOWLEDGE that by displaying a Retired Volunteer Firefighter Plates or Retired Ground Search and Rescue Plates I am not granted any authority to exceed posted speed limits or claim extra right-of-way and I also absolve the Province of Nova Scotia from any civil liability resulting from any accident. Signature of Applicant Date SECTION 4 To Be Completed by Chief or Deputy Chief / SAR Team President Volunteer Fire Department / Ground Search and Rescue Organization Address Telephone Number I HEREBY CERTIFY that the above noted applicant is a Retired Volunteer member of the above Fire Department or Ground Search and Rescue Organization. Signature of Chief or Deputy Chief or Team President Date NOTE: For purposes of this Application a Retired Volunteer member means a person who: was a member of a Volunteer Fire Department or Ground Search and Rescue Organization for 15 years and while active participated in a minimum of 20% of calls and training.

3 form APP46 (Rev. 09/15) 2004D.


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