Form Mvd-10353 - Application For Military Service Special Plate
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1
2New Mexico Taxation & Revenue Department - Motor Vehicle Division
MVD–10353
REV. 11/14
Application for
Military Service Special Plate
BEFORE COMPLETING APPLICATION PLEASE READ "GENERAL INFORMATION" ON PAGE TWO OF THIS FORM
PHONE
APPLICANT
NUMBER
NAME
EMAIL
ADDRESS
ADDRESS
CITY, STATE,
ZIP CODE
VEHICLE INFORMATION: Vehicle must be currently titled & registered in New Mexico in applicant's name.
YEAR
BODY TYPE
MAKE
MODEL
(SERIES)
VEHICLE IDENTIFICATION
CURRENT LICENSE
NUMBER (VIN)
PLATE NO.
In all cases, submit a copy of form DD-214, honorable discharge certificate and any other
MILITARY SERVICE
INFORMATION:
documentation supporting your request for special plate and decal.
NAME (as it appears on DD-214
or other military service documentation)
DATE
DATE ENTERED
BRANCH
OF BIRTH
SERVICE
OF SERVICE
SERVICE
SOCIAL SECURITY
VETERAN'S ADMIN.
NUMBER
NUMBER
CLAIM NO.
INDICATE SPECIAL LICENSE PLATE YOU ARE APPLYING FOR:
Army Veteran
Woman Veteran
Medal of Honor
ONE TIME, $17.00 FEE IN ADDITION
ONE TIME, $17.00 FEE IN ADDITION
DATE AWARDED:
TO REGULAR REGISTRATION FEE.
TO REGULAR REGISTRATION FEE.
Navy Veteran
Purple Heart
Purple Heart Motorcycle
ONE TIME, $17.00 FEE IN ADDITION
DATE AWARDED:
DATE AWARDED:
TO REGULAR REGISTRATION FEE.
Marine Corps Veteran
Ex-Prisoner of War
Ex-Prisoner of War Motorcycle
DATES OF CONFINEMENT:
DATES OF CONFINEMENT:
ONE TIME, $17.00 FEE IN ADDITION
to
to
TO REGULAR REGISTRATION FEE.
Air Force Veteran
Disabled Veteran
Disabled Veteran Motorcycle
ONE TIME, $17.00 FEE IN ADDITION
DATE DECLARED 50% DISABLED:
DATE DECLARED 50% DISABLED:
TO REGULAR REGISTRATION FEE.
Coast Guard Veteran
Armed Forces Veteran
Veteran Motorcycle
ONE TIME, $17.00 FEE IN ADDITION
ONE TIME, $9.00 FEE IN ADDITION
ONE TIME, $17.00 FEE IN ADDITION
TO REGULAR REGISTRATION FEE.
TO REGULAR REGISTRATION FEE.
TO REGULAR REGISTRATION FEE.
LICENSE PLATE DECALS
SELECT 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
Navy Cross
Combat Wounded
Viet Nam
Navy
Air Force Cross
Bataan Survivor
Grenada
Marine Corps
Silver Star
Navajo Code Talker
Panama
Air Force
Dist. Flying Cross
Atomic Veteran
Desert Storm
Coast Guard
Bronze Star
Woman Veteran
Afghanistan
Dist. Service Cross (Army)
Purple Heart
World War II
Iraqi Freedom
Korea
APPLICANT'S CERTIFICATION: I hereby certify that the
VETERANS SERVICE COMMISION CERTIFICATION:
information given above and any accompanying documentation
I hereby certify that applicant's request for special plate and decal
is true and correct to the best of my knowledge.
is supported by accompanying documentation.
Applicant's Signature
Date
Approved By
Date
Mail completed form to: MVD - Vehicle Services Bureau, P .O. Box 1028, Santa Fe, NM 87504-1028
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