FLEET MANAGEMENT SERVICES
STATE LICENSE PLATE DESIGNATION EXEMPT FORM
NOTE: All state-owned vehicles will have a "STATE" license plate. To be exempt from this policy please complete this form and
return it to FMS. The requesting agency head must sign below before the request will be processed. All requests for standard
vanity or undercover license plates also requires approval from the Secretary of Administration or their designee.
VEHICLE INFORMATION
Current License Plate Number:
Make:
Model:
Year:
AGENCY/DEPARTMENT INFORMATION
Requesting Agency/Department:
Date:
Driver Name:
Title:
Email:
Main Contact:
Phone Number:
Email:
PARKING INFORMATION
Parking location Saturday / Sunday or between 7pm and 5am. Please include the complete address.
VEHICLE USE INFORMATION
Is this a take home vehicle:
Yes
□
No
□
Is this vehicle used off-hours? (Saturday/Sunday or between 7pm and 5am): Yes
□
No
□
REQUEST JUSTIFICATION
Describe the nature of investigative/surveilance/enforcement activities and the impact of a confidential tag on the integrity of
that investigation. Also, describe any employee and/or vehicle property security concerns. Use back of form if needed.
FMS POLICIES
By signing this request, the undersigned agrees to have the employee abide by all of the policy set forth by FMS and AOA Bulliten
2.3. For a complete list visit our website:
SIGNATURE AND APPROVAL
Request Approved by Agency / Department Head
Signature:
Date:
Secretary of Administration or Designee Approval
Name:
Title:
Department:
RETURN COMPLETED FORM WITH A COVER LETTER FROM THE DEPARTMENT HEAD TO PENNY
TOUCHETTE: penny.touchette@state.vt.us OR THE ADDRESS LISTED BELOW
FMS Office: 7 Green Mountain Drive, Montpelier VT 05620-4502 • P: 802-828-3821 • F: 802-828-3886