Application For Nonprofit Public Service Organization Collector Plates - Michigan Department Of State

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MICHIGAN DEPARTMENT OF STATE
APPLICATION FOR NONPROFIT PUBLIC SERVICE ORGANIZATION COLLECTOR PLATES
Collector versions of each approved nonprofit public service organization license plate can be purchased for a one-time fee of $10 each. These
plates are for display purposes only - not for vehicle registration. Complete this form, including your name and address, to purchase by
mail or fax.
________ Grand Lodge of Free and Accepted Masons
________ Michigan State Fire Fighters Union (Union)
________ Police Officers Association of Michigan
________ Michigan State Firemen’s Association (Volunteer)
________ Fraternal Order of Police
0
Total # Plates =
________
x $10.00
0.00
Total Fees =
$________
To Purchase by MAIL: Complete the order form. If paying by check or money order, make payable to State of Michigan. If paying by credit
card, complete the credit card section below. Mail this completed application to: Michigan Department of State, Renewal by Mail Unit,
Lansing, MI 48918.
To Purchase by FAX: If purchasing by fax, you must pay by credit card. Fax this completed application to (517) 322-6822 - 24 hours a day, 7
days a week.
Mailing Information (required)
NAME: ________________________________________________________________________________________________________
ADDRESS: ________________________________________________ CITY: _______________ STATE: ___________ ZIP: _________
DAYTIME TELEPHONE NUMBER: (__________) _____________ - _________________
Credit Card Information (if paying by credit card)
My payment is by:
Visa
MasterCard
Discover
Check (enclosed)
Money Order (enclosed)
Credit Card Number:
Expiration Date:
Total Fees:
0.00
.
$
My signature below authorizes the Michigan Department of State to charge my account.
Please SIGN your name:
X_____________________________________________________________
Please PRINT your name:
______________________________________________________________
February 2013 - MDOS Internet Form (Nonprofit Public Service Organization Collector Plate Application)

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