State Form 55352 Application For Construction Of Public Sewer

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PETITION FOR PARTICIPATION IN THE SPECIAL GROUP

RECOGNITION LICENSE PLATE PROGRAM

State Form 55352 (8-13)

INDIANA BUREAU OF MOTOR VEHICLES

INSTRUCTIONS: This petition is used to support an application for a special group recognition license plate. The organization must also complete an

application (State Form 54852) which is subject to review under IC 9-18-25. This petition must be filed with the Bureau of Motor Vehicles by the

applicant on or before 3 pm ET April 1. Application is for plate issuance the following registration year. This petition must contain the original

signatures of at least five hundred (500) residents of Indiana who pledge to purchase the special group recognition license plate in accordance with

IC 9-18-25-2.3(a)(8), to meet an application for participation requirement (attach and number additional pages, as needed). The petition must be

submitted with the application (State Form 54852). The BMV reserves the discretion to deny an application if the pledge list is incomplete or appears

fraudulent.

TO THE INDIANA BUREAU OF MOTOR VEHICLES:

Each of the undersigned represents that the individual is a resident of the state of Indiana, resides at the address provided on this petition, and by

signing this petition, is pledging to purchase this organization’s specialty license plate in the event the application is approved and the license plate is

available for registration.

APPLICANT INFORMATION

Name of Organization

Organization Address (number and street)

City

State

ZIP Code

Organization Application Contact Name

Contact Telephone Number

Contact E-mail Address

INDIANA ADDRESS

DATE