Form Mv-412 - Application For Military And Veteran Custom Plates - New York State Department Of Motor Vehicles Page 3
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1
2
3APPLICATION FOR MILITARY AND VETERAN CUSTOM PLATES
IMPORTANT: Making a false statement in any registration application or in any proof of statements in connection with it, or deceiving or
substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in
the revocation or suspension of the registration and/or the applicant’s license pursuant to regulations established by the Commissioner. The
act of renewing these plates shall constitute your certification that you remain eligible to continue holding these plates.
PLEASE PRINT INFORMATION BELOW
Which military/veteran plate are you applying for?
(Refer to the list on pages 1 and 2.)
(Example: Former POW, Purple Heart, U.S. Veteran, etc.)
___________________________________________________________________________
Last Name
First
M.I.
Date of Birth (Month/Day/Year)
/
/
Address (Include Street Number and Name and/or Rural Delivery Box No.)
check if new Apt. #
City
State
Zip Code
Signature (Sign Name in Full)
Date
Daytime Phone (include area code)
ç
(
)
/
/
Vehicle Model Year
Vehicle Make
Current Plate Number
Plate type:
o
o
o
Passenger
Commercial
Motorcycle
o
o
If you need the Symbol of Access on your new plates and you do not have it on your current plates,
Do your current plates have the Symbol of Access (SA)?
Yes
No
you must also submit a completed form MV-664.1, which may be printed from the DMV web site.
I would like to apply for:
o
o
o
Standard plates (number assigned by DMV)
Personalized plates
SA Requested (You must qualify)
Personalized Motorcycle Plates (US Veteran, MCL, Purple Heart, Vietnam Veteran and DAV only) (see DAV eligibility
details on page 1)
The military emblem or picture will be shown on the left side of the plate. A maximum of four spaces is allowed for the letter/number
combination. If the Symbol of Access is required, only three spaces are allowed. You may provide up to three letter/ number combination
choices. To show a space, put a period (.) on the line in the choice where you want the space. DMV reserves the right to reject, recall or
cancel any plate that is deemed objectionable. This includes plates that have already been issued.
1st ____ ____ ____ ____
2nd ____ ____ ____ ____
3rd ____ ____ ____ ____
Amount Enclosed $
__________________
o
o
Master Card
Visa
Do you receive all of your veterans’ benefits?
For free assistance, call the NYS Division of Veterans’ Affairs at 1-888-838-7697
PAGE 3 OF 3
MV-412 (10/17)
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