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Get WV DMV-41-TR 2013

Motor Vehicles Plate and/or Placard Detail Mail to: Mobility Impaired Placards & Plates • PO Box 17010 • Charleston, WV 25317 Questions: 1-800-642-9066 • www.dmv.wv.gov PART I • TO BE COMPLETED BY THE APPLICANT (You must follow the Instructions provided on the back of this form.) A.) Applicant Information • DO NOT FORGET TO ENTER YOUR SOCIAL SECURITY NUMBER IN THE LIGHT GRAY BOX ABOVE. Name LAST FIRST Gender MIDDLE Birthdate / / Phone ( ) - Address STREET ADDRESS CITY.

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