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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
13. Make of Car
15. Type
16. License Tag Number
18. Motor NO.
19. Serial Number
21. Name of Station

23. Attach copy of Certificate of Insurance as required by K. S. A. 40-3107 and 40-3118.

25. I affirm the above vehicle is in good mechanical condition.

    1. Yes
27. Ref: 1983 City Code – Sec. 27 - 38
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29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field