Limited Power Of Attorney Only For Purchase Of A Fighting Cystic Fibrosis License Plate (Page 3 of 3) in pdf

Limited Power Of Attorney Only For Purchase Of A Fighting Cystic Fibrosis License Plate Page 3

Limited Power of Attorney

ONLY for Purchase of a Fighting Cystic Fibrosis License Plate

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

Address: _________________________________________________________________________

City: __________________________, County: ______________________, Alabama ZIP: ________

Phone (Home): ______________________, Phone (Daytime): ______________________________

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

do hereby appoint a Representative of Laps for CF, 6 Office Park Circle, Suite 209, Birmingham, AL

35223 limited attorney‐in‐fact to do all things necessary for the limited purpose of obtaining a distinctive

Fighting Cystic Fibrosis License Plate for my motor vehicle(s) described as follows:

Year of

Make of Vehicle

Model of Vehicle

Vehicle

Vehicle Identification Number (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 Fighting Cystic Fibrosis License Plate Page 3