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National Choose Life

Online Application

Fill out the fields below, then click on Submit to open a copy of your application for printing.
If you would like to complete the application by hand, simply click on Submit without completing any of the information below to open a blank copy of your application for printing.

Title Number:

Registration Plate Number:

Expiration Date:
Use format: MM/YYYY

Make of Vehicle:

Year:

Last Name (or Full Business Name):

Fist Name:

Middle Name:

PA DL/Photo ID# or Bus. ID#:

Date of Birth:

Home Phone:

Office Phone:

E-Mail Address:

Street Address - Must list a street address. P.O. Box # alone is not acceptable.:

City:

State:

Zip Code:

Number of Duplicate Registration Cards Requested @ $2 each:

Optional Personalization Request
First choice:

Second choice:

Third choice:
Note: Additional $104 Fee Required for Personalization.
Personalized registration plate choices may contain up to FIVE letters or numbers in combination. Only one hyphen or space is permitted, but not both as part of the available spaces for personalization. No other special characters are available.

Notes:

Date:

Affiliate: