PMCH License Plate Renewal - St.Vincent Hospital Foundation

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Thank you for your interest in supporting Peyton Manning Children's Hospital at Ascension St. Vincent through the purchase of a special group recognition license plate. As part of the 10-year renewal application process for this plate, we must collect at least 500 signatures of individuals who pledge to purchase the plate, pending the approval of the renewal application.

The electronic signature created by completing and submitting the simple form below will qualify as an allowable signature for the purposes of this participation pledge. Please complete the form in its entirety, including your name, full mailing address (No P.O. Boxes), a typed e-signature, and the date of your submission.

Thank you again for your partnership with Peyton Manning Children's Hospital at Ascension St. Vincent.

Peyton Manning Children's Hospital - License Plate

Please complete the information below.

First and Last Name*

Indiana Address (Street, City, State and Zip Code - No PO Boxes)*

E-Signature (By signing, I attest that I am a resident of the state of Indiana, reside at the address provided on this petition, and pledge to purchase this organization's distinctive license plate in the event the application is approved and the license plate is available for registration.)*

Date (mm/dd/yyyy)*

How to order your license plate

Visit the Bureau of Motor Vehicles website here to order the Peyton Manning Children’s Hospital license plate today. The cost of the plate is $40 annually, $25 supports the Child Protection Team at the hospital.

Ascension St. Vincent Foundation \| 8402 Harcourt Road Suite 210 Indianapolis, IN 46260
Phone: (317) 338-2338 \| Fax: (317) 338-2171