Form Hsmv 83034 - Application For Military Service Related License Plates

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FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
APPLICATION FOR MILITARY SERVICE RELATED LICENSE PLATES
SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE OR LICENSE PLATE AGENCY
ALL APPLICATIONS FOR MEDAL OF HONOR, SILVER STAR, DISTINGUISHED SERVICE CROSS, NAVY CROSS, OR AIR
FORCE CROSS MUST BE SUBMITTED TO THE DIVISION OF MOTORIST SERVICES
(see reserve side for address)
See Reverse Side of this form for Provisions of Law and Instructions
1.
I, ____________________________________________ hereby certify that I am a legal resident of Florida, residing at
_______________________________________________________________________________________________________________
(Address)
(City)
(State)
(Zip)
and I am the registered owner of the following described motor vehicle:
YEAR _________
MAKE ____________________
CURRENT LICENSE PLATE NUMBER ______________________________
TITLE NUMBER __________________
VEHICLE IDENTIFICATION NUMBER _____________________________________________
OWNER/LESSEE'S DATE OF BIRTH __________ SEX ___ OWNER/LESSEE'S DL NUMBER _________________________________
OWNER/LESSEE’S EMAIL ADDRESS: _______________________________________________________________________________
2.
This is to certify that I, ________________________________________________, am applying (and providing proof of eligibility, as
listed below) for the following license plate as indicated:
Ex-Prisoner of War
Purple Heart
Medal of Honor
Pearl Harbor Survivor
US Paratrooper
Operation Iraqi Freedom
Operation Enduring Freedom
Gold Star
Fraternal Order of Police
Combat Infantry Badge
Combat Action Badge
Vietnam War Veteran
Korean War Veteran
Silver Star
Distinguished Service Cross
Navy Cross
Air Force Cross
Operation Desert Shield Veteran
Operation Desert Storm Veteran
Ex-Prisoner of War or Un-remarried
Proof from the US Government of being a legal ex-prisoner of war while in the service of the Armed Forces
Surviving Spouse of Ex-Prisoner of War
of the United States or as a civilian serving with the consent or authorization of the US Government.
Purple Heart Medal Recipient or
Un-remarried Surviving Spouse of
Proof from the US Government of being a recipient of the Purple Heart Medal.
Purple Heart Medal Recipient
Medal of Honor
Proof from the US Government of being a recipient of the Medal of Honor.
Proof of membership in the Pearl Harbor Survivors Association or proof of active military duty in Pearl Harbor
Pearl Harbor Survivor
on December 7, 1941.
Proof of completion of US Army Jump School or of being decorated as a parachutist during military training.
US Paratrooper
($20 annual use fee and $5 processing fee is required).
Proof of active or former military duty in Iraq during Operation Iraqi Freedom or in Afghanistan during Operation
Operation Iraqi Freedom
Enduring Freedom or proof the applicant was awarded the Southwest Asia Service Medal, Iraq Campaign
Operation Enduring Freedom
Medal, Afghanistan Campaign Medal, or Global War on Terrorism Expeditionary Medal as appropriate.
Proof from the US Government that the service member was killed while serving and proof of relationship to
Gold Star
the service member.
A copy of a notarized letter from the Florida State Lodge of the Fraternal Order of Police must be submitted
Fraternal Order of Police
stating that the applicant is a member of the lodge in good standing or a family member of a lodge member.
Proof from the US Government of being a recipient of the Combat Infantry Badge or proof of membership
Combat Infantry Badge
In the Combat Infantrymen’s Association, Inc.
Combat Action Badge
Proof from the US Government of being a recipient of the Combat Action Badge.
Proof from the US Government of being deployed and serving in Vietnam during the military deployment in
Vietnam War Veteran
Indochina. Proof that the applicant was awarded the Vietnam Service Medal.
Proof from the US Government of being deployed and serving in Korea during the military deployment in Korea.
Korean War Veteran
Proof that the applicant was awarded the Korean Service Medal.
Navy Cross
Distinguished Service Cross
Proof from the US Government of being a recipient of the Navy Cross, Distinguished Service Cross, Silver Star,
Silver Star
Air Force Cross
or Air Force Cross.
Proof from the US Government that a current or former member was deployed and served in Saudi Arabia,
Operation Desert Shield Veterans
Kuwait, or another area of the Persian Gulf during Operation Desert Shield or Operation Desert Storm or proof
Operation Desert Storm Veterans
the applicant was awarded the Southeast Asia Service Medal, Iraq Campaign Medal, Afghanistan Campaign
Medal, or Global War on Terrorism Expeditionary Medal as appropriate.
________________________________________________________
______________________
Applicant's phone number
Signature of the applicant for the above indicated license plate
HSMV 83034 - REV. 06/14

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