Form Rv-F1313901 - Emergency License Plate Authorization - Tennessee Department Of Revenue
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TENNESSEE DEPARTMENT OF REVENUE
TAXPAYER AND VEHICLE SERVICES DIVISION
EMERGENCY LICENSE PLATE AUTHORIZATION
FORM RV-F1313901—SIDE A
If selling an emergency vehicle use Side B
Complete this form if E-Plates, Firefighter, Rescue Squad or Trauma Physician Plates are requested
NOT REQUIRED FOR IAFF OR FOP PLATES
(This form is not necessary for renewal of emergency plates, just check name against current agency listing)
SECTION 1. GENERAL INFORMATION
Full Name Of Person Requesting Emergency Plates _____________________________________________________________
Is A Member of or Retired Firefighter with the ________________________________in ____________________________, TN
(Name of Fire or Police Precinct, Rescue Squad
or Emergency Management Association)
Or Is A Trauma Physician, Nurse or On call Surgical staff at_______________________________________________________
Name of Hospital or Medical Center
Residential Address_______________________________________________________________________________________
City ___________________________ State ________ Zip ________________ Telephone ____________________________
Mailing Address _________________________________________________________________________________________
(If different from above)
SECTION 2. VEHICLE INFORMATION
Make ______________________ Year _____________ VIN__________________________________________________
SECTION 3.
TYPE OF PLATE AND REQUIRED DOCUMENTATION FOR OBTAINING EMERGENCY
PLATES
Type of Plate—Circle Category
E-Plate (Check one)
Auxiliary Police Unit w/Civil Defense Authorities
Required Documentation: Official Identification Card Tenn. Code. Ann. § 55-4-222(b)
Civil Air Patrol/Civil Defense Organization/Emergency Management Agency
Required Documentation: Permanent Official Registration Card and a letter from the local Civil Defense/
Emergency Management Director Tenn. Code. Ann. § 55-4-222(c)
Emergency Medical Technician/Paramedic
Required Documentation: Official Identification Card Tenn. Code. Ann. § 55-4-222(d)
Full Time Police Officer
Required Documentation: Authorization from the Chief Law Enforcement Officer of the Organization Tenn.
Code. Ann. § 55-4-222(f)
Trauma Nurse
Required Documentation: Certification from Trauma Center or Emergency room confirming that applicant is a
trauma nurse in their employment. Tenn. Code. Ann. §55-4-222(h)
On Call Surgical Personnel
Required Documentation: licensed or certified according to Tenn. Code Ann. Title 63 or as a surgical
technologist under title 68, chapter 57, serving in a hospital, emergency room or surgical department who
submits a statement or certification from such hospital, emergency room or surgical department confirming that
the applicant is on-call surgical personnel, Tenn. Code. Ann. §55-4-222(i)
Trauma Physician
Required Documentation: Statement of Certification from Board of Medical Examiners and from the
Trauma Center in a hospital or other medical facility Tenn. Code. Ann. § 55-4-222(g)
Firefighters Plate
Required Documentation: Proof of current or former* membership in a firefighting unit (retired firefighters in good
standing are now eligible for this plate) Tenn. Code. Ann. § 55-4-241
Rescue Squad Plate
Required Documentation: Badge as Member of Tennessee Association of Rescue Squads or list of
eligible members from the Captain of the local Rescue Squad Tenn. Code. Ann. § 55-4-222(d)
SECTION 4. CERTIFICATION--
Under Penalties of Perjury, I Hereby Certify This Information is Correct to the Best of My Knowledge.
_________________________________________________________________
SIGNATURE OF PERSON COMPLETING FORM
DATE
SECTION 5. APPROVAL--
THIS AUTHORIZATION FORM HAS BEEN _________ APPROVED __________ DENIED
_______________________________________________________________ (Tenn. Code Ann. § 55-2-107)
SIGNATURE OF COUNTY CLERK/DESIGNEE
DATE
RV-F1313901 (REV. 7/08)
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