License Plate Request Form

Name:*	Vehicle Owner's Name: *        Last year attended: Did you Graduate?     Yes    No
e-mail Address:
Telephone:	Home Phone Number:*
Home Address:	Address: City: State:    Zip Code: *
Type of Vehicle:	Make (e.g: Ford, Geo) Model (eg: Taurus, Tracker) Year
Type of Plate	New Plate   Renewal
Designate Funds
Payment	When you press the submit button below, you will be taken to our secure credit card form.  Please re-enter your personal information, as well as the amount of your donation.
	Please allow 7-10 days for us to process your payment and send your certificate of donation, which you will need to present to the DMV.
Please enter code to verify. Code: 5465