APPLICATION FOR TEMPORARY ... - Auto Title Express

1 LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS OFFICE OF MOTOR VEHICLES 64886 BATON ROUGE, LA 70896-4886 APPLICATION FOR TEMPORARY REGISTRATION MARKERS APPLICATION AND FEES MUST BE TAKEN TO YOUR LOCAL MOTOR VEHICLE OFFICE(PLEASE TYPE OR PRINT) APPLICATION IS HEREBY MADE BY DEALER/LENDING INSTITUTION/ Title COMPANYDEALER PERMIT NO.

2 (IF APPLICABLE)STREET OR MAIL ADDRESSCITYM arkers issued in sets of twenty-five. Fee is $ per set plus a $ service fee per order. No parish/municipality fee will be charged. INDICATE THE TYPE OF TEMPORARY MARKER AND THE NUMBER OF SETS NEEDED FOR EACH markers for autos, boat trailers, camper trailers, and trucks weighing 10,000 pounds and under. # OF SETS REQUESTED _____60-day markers for motorcycles# OF SETS REQUESTED _____10-day markers for trucks weighing over 10,000 pounds# OF SETS REQUESTED _____30-day in transit markers for autos, boat trailers, camper trailers, and trucks weighing 10,000 pounds and under# OF SETS REQUESTED _____TOTAL FEES DUE _____SIGNATURE OF AUTHORIZED REPRESENTATIVE(DO NOT WRITE IN THE SPACES BELOW - FOR OFFICE USE ONLY)

3 MOTOR VEHICLE OFFICER DATE$ _____TOTAL REMITTANCEISSUED:FROM _____ THRU _____DPSMV 1642 (R 08/05)