Form Mvd-10353 - Application For Military Service Special Plate
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2MVD–10353
New Mexico Taxation & Revenue Department, Motor Vehicle Division
REV.
7/09
APPLICATION FOR MILITARY
SERVICE SPECIAL PLATE
Before completing this application, please read the “General Information” on page 2 of this form.
Return completed form to: Motor Vehicle Division, Vehicle Services Bureau P.O. Box 1028, Santa Fe, NM 87504-1028
APPLICANT AND VEHICLE INFORMATION:
Note: Vehicle must be currently titled and registered in New Mexico in the Applicant’s name.
Applicant’s Name
Telephone number
Address
City, State, ZIP Code
Year
Make
Model
Body Type (Series)
Vehicle Identification Number (VIN)
Current Registration Plate Number
MILITARY SERVICE
In all cases, submit a copy of form DD-214, honorable discharge certificate and/or
INFORMATION:
other documentation supporting your request for special plate and decal.
Name (as it appears on DD-214 or other military service documentation)
Branch of Service
Date Entered Service
Date of Birth
Service Number
Social Security Number
Veterans’ Admin. Claim Number
Special License Plate Applied For
Armed Forces Veteran
Army Veteran
Navy Veteran
One-time $17.00 fee in addition to
One-time $17.00 fee in addition to
One-time $17.00 fee in addition to
regular registration fee
regular registration fee
regular registration fee
Marine Corps Veteran
Air Force Veteran
Coast Guard Veteran
One-time $17.00 fee in addition to
One-time $17.00 fee in addition to
One-time $17.00 fee in addition to
regular registration fee
regular registration fee
regular registration fee
Ex-Prisoner of War
Medal of Honor
Purple Heart
Dates of confinement
Date awarded ________________
Date awarded ________________
___________________________
Disabled Veteran
Veteran Motorcycle
Disabled Veteran Motorcycle
Date declared
One-time $9.00 fee in addition to
Date declared
100% disabled ______________
regular registration fee
100% disabled ______________
License Plate Decal
Select only one (1) of the following decals to be affixed in the top center depression on your license plate.
Caution: Application will be rejected if choice of decal is not supported by accompanying documentation.
Army
Silver Star
Korea
Navy
Distinguished Flying Cross
Viet Nam
Marine Corps
Bronze Star
Grenada
Air Force
Combat Wounded
Panama
Coast Guard
Bataan Survivor
Desert Storm
Distinguished Service Cross (Army)
Navajo Code Talker
National Guard
Navy Cross
Atomic Veteran
Afghanistan
Air Force Cross
World War II
Iraqi Freedom
Applicant’s Certification
Department of Veterans’ Services Certification
I hereby certify that the information given above and any
I hereby certify that Applicant’s request for special plate
accompanying documentation is true and correct to the
and decal is supported by accompanying documentation
best of my knowledge.
and/or Applicant’s service record.
____________________________
___________
____________________________
___________
Applicant’s Signature
Date
Approved by
Date
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