Application for Military
For County Use Only
Disabled Veteran License Plates
License Number
and Parking Placards
Mo/Yr of Exp
Date Issued
Applicant Information
First Name
Middle Name
Last Name
Suffix, if any
County
Mailing Address
City
State
Zip
Email
Driver License No.
Day Phone
Only one of your vehicles is eligible for a $3 specialty license plate fee. Additional vehicles may display a Disabled Veteran license plate, however,
full registration and local fees are applicable. The International Symbol of Access (ISA
) is not available for passenger and light trucks; however
you may receive a Disabled Person Placard for every vehicle that displays Disabled Veteran license plate.
Vehicle 1
An annual $3 specialty license plate fee applies.
Make
Model
Empty Weight (lbs.)
Current Plate
Year
Vehicle Identification Number
Choose your vehicle type
Passenger car or truck WITH a Disabled Parking Placard
Passenger car or truck; no parking placard
Motorcycle/moped WITH an ISA symbol on the plate
Motorcycle or moped; no ISA symbol
Vehicle 2
Annual vehicle registration and local fees apply.
Make
Year
Current Plate
Model
Empty Weight (lbs.)
Vehicle Identification Number
Choose your vehicle type
Passenger car or truck WITH a Disabled Parking Placard
Passenger car or truck; no parking placard
Motorcycle/moped WITH an ISA symbol on the plate
Motorcycle or moped; no ISA symbol
Proof of Eligibility
To be completed by a U.S. Department of Veterans Affairs Regional Office, or appropriate service branch.
The records of this agency reflect the following service-connected disability rating for the above named veteran (check one):
50 percent or more
40 percent or more due to amputation of a lower extremity
Comment (if any)
Agency
Address
Name and Title of Certifying Officer
Certifying Officer Signature
Date
Certification
State law makes falsifying information a third degree felony.
Signature of Applicant
Date
Page 1 of 2
Form VTR-615 Rev 02/17
Online form available at