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Get AZ 40-0112 2014-2024

RD RENEWAL/REPLACEMENT REQUEST  Hearing Impaired Placard  Replacement (placard was lost, stolen, destroyed or mutilated; if mutilated must be returned) Applicant Name (person with a disability or hearing impaired or organization) Phone ( ) Applicant Mailing Address City Organization Representative Name  Individuals  Organizations Current Placard Number State Zip Title I certify that I have a permanent disability or hearing impaired as stated on my original application for.

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