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2. Date of Application
   Date of Application
3. Registration Number

   (completed at inspection)

5. CONTACT INFORMATION FOR REGISTERING PARTY
7. Name (F, M, L)
8. Primary Operator Driver's License Number
10. Address
12. Phone: Home/Cell
13. Phone: Work
14. Email
16. VEHICLE INFORMATION
18. Type of Vehicle
20. Make, Model and Weight (Max 1,500 lbs)
21. Vehicle Identification Number (VIN)
23. Insurance Carrier
24. Insurance Primary Number/Issue Date
26. APPLICATION CERTIFICATION

    I (the above-named applicant) have read the contents of this application and the answers contained herein are complete and true. In addition, I have read and understand all applicable rules and regulations as set out in the Municipal Code (Ord. No. G-1422) of the City of El Dorado, Kansas. Furthermore, I hereby agree to comply with all the laws of the State of Kansas, and all rules and regulations prescribed by the City of El Dorado, and I have consent to the immediate revocation of my license, by the proper officials, for any violation of such laws, rules, or regulations.

28. Signed

    (please type name)   (Applicant must be 18 years of age or older)

29. Date
31. VEHICLE INSPECTION

    ___ Seatbelts                                  ___ Headlights
    ___ Stop and Turn Signals            ___ Windshield
    ___Muffler                                       ___ Other: _____________________

33. _________________________________

    Police Approval Printed Name

34. _________________________________

    Police Approval Signature

35. ______________________

    Date

Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field