CONCORDIA BARCODE FORM

Barcode #:_______________ Date Issued/Change:_________________

Residents Street Address:_____________________________________
Resident Last Name:

_____________________________________

Resident First Name:

___________________Email:_____________

Resident Home Phone Number:

___________Resident Year of Birth: 19__

Vehicle Registered to (First & Last Name)_________________________

If same as above check here

__________________________

If address is different list here:

__________________________

License Vehicle Make:________________ Vehicle Model:_____________

Vehicle Color:____________ State/Plate No.______________________
Is the Barcode issued above for

Additional Vehicle for the household?

Barcode Replacement?
Replacement Vehicle (Traded, Sold, Etc)*

*If for a Replacement Vehicle, or Barcode Replacement complete below:

***A $5.00 Fee is required, Payable to the Concordia Homeowners Assoc.***

Previous Barcode Number:______________________
Previous Vehicle Make:

______________________

Previous Vehicle Model:

______________________

Previous Vehicle Year:

______________________

Previous Vehicle Color:

______________________

NOTE: A completed
Census Form must
be on file before a
Barcode can be
issued.

Previous License State/Plate No. ________________

OFFICE USE ONLY

Form completed by:
Version #6
7/7/2012