PHILIPPINE INSTITUTE OF CIVIL ENGINEERS, INC.

(PICE) 72ND FOUNDING ANNIVERSARY COMMEMORATIVE LICENSE PLATE APPLICATION FORM

Application/ Registration Number: _________________ I am applying for a ____ STANDARD PLATE/ READY TO USE (CIVIL ENGINEER)

____ PERSONALIZED PLATE

If you are applying for a personalized license plate: GIVE 3 PREFERRED NAMES WITH #1 AS THE MOST PREFERRED. MAXIMUM OF 6 ALPHANUMERIC CHARACTERS. NO SPECIAL CHARACTERS ALLOWED (i.e. *, -, #,&,+) PREFERRED PLATE NAMES: Choice #1 ______ ________ ________ _________ _________ _________ Choice #2 _______ ________ ________ _________ _________ _________ Choice #3 _______ ________ ________ _________ _________ _________ Note: PICE reserve the right to reject words or names that may project a negative image for the organization. If you have not submitted a photocopy of your current vehicle certificate of registration (CR) and official receipt (OR), please attach to this application. REGULAR LICENSE PLATE NUMBER: _____ _____ _____ ----- ______ ______ _______ LTO CURRENT OFFICIAL RECEIPT (O.R.) NUMBER:______________________________________ LTO CURRENT CERTIFICATE OF REGISTRATION (C.R.) NUMBER: _________________________ VEHICLE/ MAKE: _______________________ YEAR/ MODEL: ____________________________ REGISTERED OWNER OF VEHICLE: ___________________________________________________ PERSON USING/ ASSIGNED TO THE VEHICLE: __________________________________________ ADDRESS OF VEHICLE USER: _______________________________________________________ CONTACT TELEPHONE NUMBER: ____________________________________________________
The PICE 72ND Founding Anniversary Commemorative License Plate is valid until August 30, 2010 as approved and authorized by the Land Transportation Office (LTO) and Department of Transportation and Communications (DOTC). Please attach a photocopy of your vehicle certificate of registration and current official receipt. TERMS AND CONDITIONS I hereby accept this PICE 72ND Founding Anniversary Commemorative License Plate upon full payment of a one-time subscription fee. As subscriber of this PICE commemorative license plate, I obligate myself to protect and keep the name of PICE untarnished. I submit myself to all the rules and regulations of acquiring the PICE commemorative license plate under the governing guidelines of Presidential Memorandum No. 405 and LTO Memorandum dated November 6, 1996 and October 6, 1997 respectively, specifying the rules and regulations in using commemorative license plate. 1.) 2.) 3.) 4.) The commemorative license plate shall be superimposed over the regular front vehicle plate. Removal of any of the regular plate to accommodate the commemorative license plate is strictly prohibited; The commemorative conduction sticker should be placed on the front windshield; The certification of authorization (CA) together with the machine copy of the LTO Certificate of Registration (CR) and Official Receipt (OR) must be retained inside the motor vehicle at all times; The unauthorized transfer of the commemorative plate to another vehicle is strictly prohibited and must only be attached to the motor vehicle issued this commemorative plate.

_____________________________________________. Signature of Applicant or Vehicle User over Printed Name

___________________ Date

THIS APPLICATION FORM IS NOT FOR SALE AND MAY BE PHOTOCOPIED