Free 12798.FH11 - Indiana

APPLICATION FOR DEALER PLATES & ADDITIONAL DEALER PLATES
State Form 12798 (R7 / 5-08)

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SECRETARY OF STATE - DEALER DIVISION 6400 East 30th Street Indianapolis, Indiana 46219 Telephone: (317) 591-5303 Fax: (317) 591-5319

INSTRUCTIONS:
Name of business

Complete application in full.

Address (number and street, city, state, and ZIP code)

Dealer number

Telephone number

(
Type of dealer plates applying for (check one)

)
Wholesale Dealer Transfer Dealer Motorcycle Dealer - New Motorcycle Dealer - Used

Dealer - New Manufacturer Dealer - Used
Dealer plates requested (check one)

Mobile Home Dealer Trailer Dealer Recreational Vehicle Dealer Two (2) Motorcycle Dealer plates Additional Motorcycle Dealer plates

If requesting additional plates, please indicate quantity requested.

Two (2) Dealer plates Additional Dealer plates
Signature of owner, partner, or officer

I hereby certify, under penalty of perjury, that the answers and information contained in this application are true and correct.
Date (month, day, year)

Print or type name of owner, partner, or officer

Title