Petition for Participation in the Indiana Bureau of Motor Vehicles Special Group Recognition License Plate Program

This petition will be used to support an application for a special group recognition license plate. Signing and submitting this form represents that you are a resident of the state of Indiana, reside at the address provided on the petition, and by signing the petition, are pledging to purchase an Indiana Concerns of Police Survivors distinctive license plate (graphic shown is a sample design only) in the event the application is approved and the license plate is available for registration.