Fillable Form Vsa 10 - License Plate Application printable pdf download

VSA 10 (12/10/05)

Page 1

LICENSE PLATE APPLICATION

Purpose:

Use this form to request souvenir, standard, personalized, or special license plates. Special license plate fees can be $10, $15,

or $25 annually or a one-time $10 fee, in addition to the standard registration fees. Personalization is an additional $10

annually.

Instructions: Return this form, with the appropriate fees, to any DMV customer service center or DMV Select Center. You may also mail the

application and fees to Special Plates at the address above or apply online at

. For more information,

review the Additional Information Section on the back of this form. All other inquiries can be answered by calling our customer

contact center at 1-866-DMV-Line (1-866-368-5463), or 1-800-435-5137.

PLATE INFORMATION

APPLICATION REQUEST: (

VEHICLE LICENSE PLATE

SOUVENIR LICENSE PLATE

TRANSFER EXISTING LICENSE PLATE

check one)

TYPE OF PLATE: (

check one)

STANDARD

LIGHTHOUSE

(VA 400

Anniversary)

(Blue and White)

HERITAGE

SCENIC

(Dogwood-Cardinal)

(Mountain To Seashore)

(Autumn)

(Patriot)

COLLEGE: __________________________ Locality:

City

County ______________

MILITARY___________________________________

(No Initials or Abbreviations)

SPECIAL INTEREST: ______________________________________________________

CLEAN FUEL_______ ____________ ___________

(If organization has more than one license plate, specify design type)

Year

Make

Model

OTHER___________________________________

(Any other plate not listed above)

PERSONALIZED PLATES: (Check this box if you wish to personalize your vehicle or souvenir plate.)

Indicate your choices in order of preference. The maximum number of characters allowed on standard and scenic plates is 7 ½. The maximum number of

characters allowed on a heritage plate is 6 ½, and 6 characters for all other plates bearing logos. Plates with logos may sometimes accommodate an additional ½

space when personalized. Ask a DMV representative or create a plate on our website listed above to determine availability. A blank space, and a dash, are the

only two characters that are ½ character. An ampersand, considered a full character, may be used. Spaces, dashes, and ampersands cannot be used consecutively.

CHOICE

DMV USE ONLY

Enter Available Choice: _____________

Fee: $__________________

APPLICANT INFORMATION

OWNER'S LAST NAME

FIRST

DAYTIME TELEPHONE NUMBER

(

)

DAYTIME TELEPHONE NUMBER

CO-OWNER'S LAST NAME

FIRST

(

)

CURRENT MAILING ADDRESS

CITY

STATE

ZIP CODE

CURRENT PLATE NUMBER

PLATE TYPE

PLATE EXPIRATION DATE

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER

IF PAYING BY CREDIT CARD, ENTER CARD NUMBER AND EXPIRATION DATE

CERTIFICATION/SIGNATURES

I/We certify that (Check only ONE box)

This vehicle is insured with liability coverage by a company licensed to do business in Virginia. Coverage must be in effect at the time of application and must

remain in effect as long as the vehicle is registered, even if the vehicle is not driven or is inoperable.

This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. This fee provides NO insurance coverage.

Failure to comply with Virginia's insurance requirements will result in suspension of your driver's license and vehicle license plates. I

certify that all information contained herein is true and correct. For a corporation, an authorized representative must sign.

APPLICANT'S SIGNATURE

DATE

CO-APPLICANT'S SIGNATURE