Form Mv-14ev - Application Form For Emergency Vehicle Registration Plate
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3MV-14EV (12-16)
APPLICATION FOR EMERGENCY VEHICLE
REGISTRATION PLATE
For Department Use Only
Bureau of Motor Vehicles • P.O. Box 68290 • Harrisburg, PA 17106-8289
When applying for issuance or transfer of an Emergency Vehicle registration plate, complete this supplemental application in its entirety and
attach to either Form MV-1, MV-4ST, MV-120, MV-140 or MV-44.
A
Vehicle Identification Number
Telephone Number
Title Number
(
)
Applicant Last Name (or Full Business Name)
First Name
Middle Name
PA DL/Photo ID#
Date of Birth
or Bus. ID#
PA DL/Photo ID#
Co-Applicant Last Name
First Name
Middle Name
Date of Birth
or Bus. ID#
State
Zip Code
Street Address
City
B
This vehicle is used as indicated below:
q Fire Department Vehicle
q Police Vehicle
q Sheriff Vehicle
q Blood Delivery Vehicle
q Human Organ Delivery Vehicle
q EV Plate Fleet - Attach Form MV-670
q Owned or leased by a fire relief association and utilized by an organized paid or volunteer fire department.
Name of Fire Department: ________________________________________________________________
q Ambulance - Department of Health License #___________________________
q Armed Forces Emergency Vehicle
q Vehicle operated by a Coroner or Chief County Medical Examiner
q Vehicle operated by a Chief Deputy Coroner or Deputy Chief County Medical Examiner
q Hazardous Material Response Vehicle (_______________ certification number issued by PEMA)
q County Emergency Management Vehicle
q Basic or Advanced Life Support Squad Vehicle
q Emergency Canteen Support Service Organization Vehicle (see definition on reverse)
q Vehicle owned by or leased to a regional emergency medical services unit to respond to a potential disaster, mass casualty situation or substantial
threat to public health - Department of Health License # _______________
q Vehicle owned by a county or regional police association that is used for police transport or victim extract and operated by a police officer.
q Vehicle operated by a special agent, special agent supervisor, narcotics agent or narcotics agent supervisor while performing
official duties as employees of the Office of Attorney General.
q Philadelphia Parking Authority Vehicle used in the enforcement of 53 Pa.C.S., Chapter 57.
q Privately owned vehicle used by any of the designated individuals listed on the reverse side of this form. A registration fee is required.
(NOTE: A letter on company letterhead indicating the individual’s title/position must be attached.)
q Vehicle owned and operated by a county correctional institution in a city of the first class and used to respond to an emergency at a correctional
institution in a city of the first class or to escort an ambulance which is transporting sick or injured prisoners in a city of the first class.
q A vehicle owned and operated by the Pennsylvania Turnpike Commission that is used by an emergency service responder as dispatched
by the Pennsylvania Turnpike Commission's Traffic Operations Center.
C
The applicant requesting this vehicle registration plate is a:
Full Registration Fee
Free Registration
$10 Processing Fee
For-Profit Corporation
County, City, Township or Borough
Nonprofit Corporation that provides
q
q
q
Emergency Medical Services or Ambulance
Volunteer Fire or Ambulance Association
(List Your Fee Exemption # _______)
q
# of volunteers _______
# of paid employees _______
Hospital (List Your Fee Exemption # ______)
q
D
OPTIONAL PERSONALIZATION REQUEST (NOTE: Additional $100 Fee Required.):
Personalized Emergency Vehicle registration plate choices may contain up to FIVE letters or numbers in combination. ONLY one hyphen or
space is permitted as part of the FIVE available spaces for personalization. No other special characters are available. Please print clearly.
Additional instructions are listed on the reverse side of this application. NOTE: The shaded boxes with a pre-printed letter configuration of
"EV" are specific to this registration plate and cannot be changed. These letters will appear on your personalized registration plate.
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE
E V
E V
E V
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