Form Dmv-54-Hba - Preliminary Interest Application For Special Plate printable pdf download

Form Dmv-54-Hba - Preliminary Interest Application For Special Plate

DMV-54-HBA

11/15

DEPARTMENT OF TRANSPORTATION

DIVISION OF MOTOR VEHICLES

PO BOX 17120

CHARLESTON, WV 25317

Preliminary Interest Application for Special Plate

HOME BUILDERS ASSOCIATION OF WEST VIRGINIA

PART I - TO BE COMPLETED BY APPLICANT

Name of Applicant _____________________________________________________________

Name(s) of owner(s) exactly as shown on current registration for vehicle you wish to register:

Name(s)

Telephone Number

Present Street Address

Current License Plate Number

City

State

Zip

Title Number

Model Year

Make

Vehicle Identification Number

INSURANCE INFORMATION

Effective date of Insurance Policy: From

To ____________________ NAIC#______________

Name of Insurance Company____________________________________________________________________________

Agent__________________________________________________ Policy Number________________________________

I hereby state that there is a motor vehicle liability policy in effect on the described vehicle in accordance with provisions of the West

Virginia Motor Vehicle Laws and certify that the statements made are true and correct to the best of my knowledge and belief under penalty of

false swearing, West Virginia Code §17A-9-1; Fraudulent Applications.

Date ______________________

Signature of Applicant

PART II – CERTIFICATION OF ELIGIBILITY BY ORGANIZATION

The HBAWV certifies that the above named applicant is eligible to receive a special organization plate.

Date

__________________________________________

_________________________

Signature of qualifying official

__________________________________________

Printed name of qualifying official

PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS

Form Dmv-54-Hba - Preliminary Interest Application For Special Plate