US-NYSCRT – Placard Issuance & Renewal

INSTRUCTIONS – VEHICLE IDENTIFICATION PLACARD

Please complete the application in full and return it along with the following required documents:

• A clear copy of your valid Driver’s License
• A copy of your current Vehicle Registration(s)
• A Money Order or Credit Card Authorization in the amount of $125 per placard
• Your expired Vehicle Identification Placard(s), if you are renewing

Important: Only one placard will be issued if the vehicle is not registered in your name.

DECLARATION

I hereby affirm, under penalty of law in the State of New York, that all information provided in this application is true, complete, and accurate to the best of my knowledge and belief. I further affirm that I have not knowingly or willfully made any false statement or submitted information I know to be untrue. I understand that providing false or misleading information may subject me to legal penalties.

I also acknowledge that the information provided may be shared solely with those responsible for processing this placard application and, when permitted or required, with law enforcement authorities.

CREDIT CARD AUTHORIZATION

To get started, replace this

I authorize US-NYS Chaplain Response Team, Inc. (US-NYSCRT) to charge the credit card provided for the amount indicated above. I agree to be bound by the terms and conditions of my cardholder agreement with the issuing bank, and I accept full responsibility for payment of this transaction.