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Other Power Driven Motility Device (OPDMD) Application

  1. (Or other credible assurance of mobility impairment, if available)
  2. (if available)
  3. Registrant required to have in his/her possession the registration while using the OPDMD as instructed in said location.
  4. (Include license plate # or registration # if applicable.)
  5. OPDMD Policy *

    I, the undersigned, have been given a copy of the Dubuque County Conservation Board's policy for OPDMD's and understand that this registration can be revoked if I am found to be disobeying any of the guidelines set forth in this registration. Furthermore, I hereby understand and agree to abide by the conditions and rules the forth by the Dubuque County Conservation Board for the use of the OPDMD.

  6. Leave This Blank:

  7. This field is not part of the form submission.