July 26, 2024, Current Paid Applications = 206

Are you ready to proudly display your profession on the back of your car? Our MSRC President, Howard Derrick, has worked diligently with a graphic design artist to design a car tag representing respiratory therapists across Mississippi. The tag looks like the picture above except for the word LIFE. The state requires that numbers be placed in this area instead of a word. Remember, the more you share about the MS-RT car tag, the faster we will get to 300!

--- INSTRUCTIONS ---

Download the car tag application here: MS RT Car Tag Application.pdf
Fill out the application. (A sample app is pictured below.)
Scan and upload the signed and completed application using the BLUE BROWSE button below.
Choose one payment option:

Credit Card On this site (Processing fees apply)	OFFLINE: Paypal @msrc2021 Venmo @MSRC-22 Note Your NAME/MS RT TAG in comments	Submit in person or Mail completed application with Check/MO to address below:
Upload application to this site.	You must fill out online registration and upload the application to this site. You may also email a completed, scanned application to [email protected].	Deanna Yates, C/O MSRC, PO Box 55, Blue Mountain, MS 38610

NOTE:
Please ensure that the correct Paypal and Venmo user names for MSRC are entered so that the payment will be received by us. We are not responsible for payments sent to the wrong account.

Sample Form:

Once we have received 300 applications with payment, we will submit them to the state.
Please retain your receipt or payment confirmation.
We will post updates on www.msrc-web.com, and our MSRC Facebook group.
If you have any questions or concerns, please email [email protected].

UPDATES:

12/1/2023 - 95 Tag Applications
3/04/2024 - 136 Paid Tag Applications
5/01/2024 - 157
6/20/2024 - 187

Upload application by clicking on blue BROWSE button:

Scan completed application and upload. DO NOT UPLOAD YOUR RECEIPT!

Browse

SELECT PAYMENT OPTION (via drop-down menu)

If using a payment other than credit card, please select how you will be paying offline.

A separate tag application FORM is required for each payment if paying for more than one tag application. (Ex: A quantity of 3 payments will require 3 uploaded, mailed, or emailed forms.)

MS RT Tag Application Quantity

($33.00/ea.)

Running Total -Discounts Applied Down Below

$0.00

Let's Represent Respiratory Care!

Name

Phone Number

Address

County

Total BEFORE coupon is applied:

$0.00

Coupon Code

Total

$0.00

If paying for a group, please enter NAME and EMAIL of each person you are purchasing a tag for. Use a comma between each person.

SCROLL DOWN FOR CREDIT CARD PAYMENT

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Paid by credit card online? If not uploading a scanned copy onto this site, please mail the signed and completed application to the address below.
If paying by check or money order please mail with application to this address:

Deanna Yates, C/O MSRC, PO Box 55, Blue Mountain, MS 38610

Billing Information (Processing fees apply. See summary above.)

Name

Payment Method

Credit Card
OFFLINE

Use a previously saved card

Credit Card

Visa
Mastercard
American Express
Discover

Save this card for future use

Address

Confirm Email

Mobile Phone Number

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