Name:*

Address:*

Unit:

City: *

State:*

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Zip Code:*

Telephone #: *

Email:*

Driver’s License #: *

State: *

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Vehicle Information

Make/Model:*

Color:*

Year:*

License Plate #:*

***You must input your first and last name and date below to sign this document.***

Signature:*

Date:*

Please Note: Any changes to the above information must be reported to the Borough Clerk’s Office immediately.

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