Department of State Growth Road User Services Division Form Number: MR30 03/18 Application for (Please box/s below) Replacement Certificate of Registration and Certificate of Premium Paid and/or Replacement Number Plates Registration Number Make (Holden, Toyota, etc.) Vehicle Type (Car, Truck, Trailer, etc.) Full Name of Registered Company/Family Name Operator/s If in joint names (light vehicles only) insert Given Names both full names Residential/Company Postcode Address Postcode Postal Address Mobile No. Which have been: Lost Damaged Destroyed Stolen ( box) Declaration by Registered Operator/s or Other No of Plates Returned: 1 2 If 1, reason Details (If applicable, box ) I, (Full Name/s) do hereby declare that the Registration Certificate or Plate/s indicated above have been lost, damaged, destroyed, stolen, or other, as detailed, and I/We request a Replacement. Signed Date
Department of State Growth Road User Services Division Form Number: MR30 03/18 Application for (Please box/s below) Replacement Certificate of Registration and Certificate of Premium Paid and/or Replacement Number Plates Registration Number Make (Holden, Toyota, etc.) Vehicle Type (Car, Truck, Trailer, etc.) Full Name of Registered Operator/s Company/Family Name If in joint names (light vehicles only) insert both full names Given Names Residential/Company Address Postcode Postal Address Postcode Mobile No. Which have been: Lost Damaged Destroyed Stolen ( box) Other No of Plates Returned: 1 2 If 1, reason (If applicable, box ) Declaration by Registered Operator/s or Details I, (Full Name/s) do hereby declare that the Registration Certificate or Plate/s indicated above have been lost, damaged, destroyed, stolen, or other, as detailed, and I/We request a Replacement. Signed Date
MR30_07_14_Application_for_Replacement_Certificate_of_Registration_Plates_002.docx