Form Mv-904 - Application For Personalized Number Plate

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MV-904 (12-16)

aPPlicatiOn FOR PERSOnaliZED,

aMatEUR RaDiO OPERatOR OR PRESS

PHOtOGRaPHER REGiStRatiOn PlatE

For Department Use Only

Bureau of Motor Vehicles • PO Box 68293 • Harrisburg, PA 17106-8293

CHECK BLOCK FOR TYPE OF PLATE DESIRED:

Personal Registration Plate - Complete Sections A, B and E. Fee: $76

amateur Radio Operator Registration Plate - Complete Sections A, C and E. Fee: $11

Press Photographer Registration Plate - Complete Sections A, B (if applicable), D and E Fee: $11 (An additional $100 fee for

personalization.)

aPPlicant anD VEHiclE inFORMatiOn (liSt inFORMatiOn cURREntlY SHOWn On titlE OR REGiStRatiOn caRD)

Last Name (or Full Business Name)

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

or Bus. ID#

Co-Owner Last Name

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

Street Address

State

City

Zip Code

Daytime Telephone Number

Home ______________________

Vehicle Identification Number

Title Number

Office ______________________

Make of Vehicle

Registration Plate Number

Expiration Date

nOtE: In conjunction with replacement of your plate, you will receive one registration card. If additional registration cards are desired, the fee is $2

for each card. number of Duplicate Registration cards Requested @ $2 each ________.

PERSOnaliZED REGiStRatiOn PlatE inFORMatiOn

The number of allotted letters or numbers in combination varies depending on the selected registration plate type. Please see the reverse side of this

application for additional instructions regarding the allotted spaces. No other special characters are available. Please print clearly.

FIRST CHOICE

SECOND CHOICE

THIRD CHOICE

EXaMPlES . . .

B U l l - D O G

S P a

c E

c R E 8 i V E

W E l

V E

nOtE: When requesting a numeric character of zero, please show as " " instead of the alpha character "O." Since this is an electronically fillable