Limited Power Of Attorney Only For Purchase Of A Hope For Kids With Diabetes License Plate (Page 3 of 3) in pdf

Limited Power Of Attorney Only For Purchase Of A Hope For Kids With Diabetes License Plate Page 3

Limited Power of Attorney

ONLY for purchase of a Hope for Kids with Diabetes License Plate

I, Name: _________________________ (as it appears on your tag receipt/registration) of

Address: _________________________________________________________________

City: _____________________, County: _____________________, Alabama Zip: ______

Phone: ______________________, Email: ______________________________________

Date of Birth: ______________________ Driver’s License #: ________________________

Do hereby appoint a Representative of Children’s of Alabama, 1600 7

Avenue South,

Birmingham, AL 35233 limited attorney-in-fact to do all things necessary for the limited

purpose of obtaining a distinctive Hope for Kids with Diabetes License Plate for my motor

vehicle(s) described as follows:

Year of

Vehicle Identification Number

Make of Vehicle

Model of Vehicle

Vehicle

(VIN)

This limited power of attorney terminates upon acceptance of this application for my

plate(s).

Signature: ___________________________________ Date: _______________________

Notary Signature: ____________________________ Date: _______________________

Notary Expiration Date: _______________________

Notary Seal or Stamp:

Limited Power Of Attorney Only For Purchase Of A Hope For Kids With Diabetes License Plate Page 3