Name of Applicant

(Name under which certificate will be issued)

Business Address

Business Phone

Name of Responsible Official

Title

Type or Mode of Equipment to be certified

Model or Identifying Number

Designed Use

Submitted as part of this application are the following:

a)

Standard commercial sample of subject equipment

b)

Copy of AAMVA Equipment Approval Certificate.

CERTIFICATION

            I, the undersigned official, empowered to act for the above applicant, certify that each item of equipment of the same model or type described in this application, and manufactured for use on or actually used on a bicycle, will fulfill the requirements of Rule 12-206 (92 Ill. Adm. Code 426) as in effect at the time the item is manufactured.

            (SEAL)

/S/

Official Capacity

Date

Accepted and Approved this

day of

, 19

            (SEAL)

/S/

Secretary, DOT