Form 4601 - Application For Missouri Military Personalized License Plates
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MISSOURI DEPARTMENT OF REVENUE
SEE INSTRUCTIONS ON REVERSE
FORM
MOTOR VEHICLE BUREAU
4601
ANY FALSE STATEMENT IN THIS APPLICATION
PO BOX 569, JEFFERSON CITY, MO 65105-0569 (573) 526-3669
IS A VIOLATION OF THE LAW AND MAY BE
APPLICATION FOR MISSOURI MILITARY
(REV. 8-2012)
PUNISHED BY FINE OR IMPRISONMENT OR BOTH.
PERSONALIZED LICENSE PLATES
(PLEASE CHECK WHICH CATEGORY OF LICENSE PLATE YOU NEED)
STEP 1
NAME MUST APPEAR AS SHOWN ON VEHICLE TITLE
Passenger
Recreational Vehicle (motor home)
Beyond Local 6 Truck
Local 6 Truck (limited to a 50 mile radius)
OWNER’S NAME
Beyond Local 12 Truck
Local 12 Truck (limited to a 50 mile radius)
Beyond Local 18 Truck
Local 18 Truck (limited to a 50 mile radius)
STREET, RR, OR P.O. BOX NUMBER
Motorcycle/Motortricycle
Beyond Local 24 Truck
Local 24 Truck (limited to a 50 mile radius)
CITY, STATE, ZIP CODE
These categories only apply to Stock Disabled Veteran license plates.
Check here to add this symbol
to your plate.
DAYTIME PHONE NUMBER
CURRENT PLATE NUMBER
(Form 1776, Physician’s Statement for Disabled Person’s License Plates
__ __ __
__ __ __ - __ __ __ __
__ __ __ __ __ __
(
)
is required. See back for more information.)
STEP 2
TYPE OF LICENSE PLATE TO BE ISSUED (Some license plates require proof of eligibility — see reverse)
Submit fee shown below with this application.
Disabled Veteran (Stock - No Fee)
Operation Enduring Freedom ($15)
Air Force ($15)
Disabled Veteran (No Fee)
Operation Iraqi Freedom ($15)
Air Medal ($15)
Distinguished Flying Cross (Stock - $15)
Operation Noble Eagle ($15)
Armed Forces Expeditionary Medal (Stock - $15)
Distinguished Flying Cross ($15)
Pearl Harbor Survivor (Stock - $15)
Armed Forces Expeditionary Medal ($15)
Former POW (Stock - No Fee)
Pearl Harbor Survivor ($15)
Army ($15)
Former POW (No Fee)
Purple Heart (Stock - $15)
Initial Request (No Fee)
Bronze Star (Stock - $15) Valor
Yes
No
Gulf War - Desert Storm or Shield (Stock - $15)
Purple Heart ($15)
Initial Request (No Fee)
Bronze Star ($15) Valor
Yes
No
Gulf War - Desert Storm or Shield ($15)
Retired Military (No Personalization Fee) ___________
BRANCH OF SERVICE
Bronze Star Placard * See info. on reverse side.
Korean War (Stock - $15)
Silver Star (Stock - $15)
Silver Star ($15)
Civil Air Patrol ($15)
Korean War ($15)
Some Gave All ($15)
Coast Guard ($15)
Legion of Merit Medal (Stock - $15)
U.S. Veteran ($15)
Combat Action Badge ($15)
Legion of Merit Medal ($15)
Veteran of Foreign Wars (VFW) ($15)
Combat Action Ribbon ($15)
Marine Corps ($15)
Vietnam Veteran (Stock - $15)
Vietnam Veteran ($15)
Combat Infantryman (Stock - $15)
Marine Corps League ($15)
Wartime Disabled ($15)
Combat Infantryman ($15)
Merchant Marine ($15)
World War II (Stock - $15)
Combat Medic (Stock - $15)
National Guard ($15)
World War II ($15)
Combat Medic ($15)
Navy ($15)
Congressional Medal of Honor (No Fee)
Navy Cross ($15)
For all license plates listed as “Stock”, the Missouri Department of Revenue will select your license plate configuration.
PERSONALIZED PLATE CHOICES (Complete only if applying for personalized plates. Please include more than one choice.)
STEP 3
TOTAL NUMBER OF CHARACTERS ALLOWED. A DASH, SPACE, OR AN APOSTROPHE COUNTS AS ONE CHARACTER. (ONLY ONE DASH,
PLATE DESIGN
ONE SPACE, OR ONE APOSTROPHE IS ALLOWED.)
NOTE: The Missouri Department of Revenue will not issue license plates that contain
6
Plates with emblem
any letters, numbers, or a combination of letters and numbers which are obscene,
Plates with emblem and
4
profane, patently offensive or contemptuous of a racial or ethnic group, offensive to
wheelchair symbol
good taste or decency, or would present an unreasonable danger to the health or
Motorcycle/motortricycle plates
5
safety of the applicant, or other users of streets and highways, or of the public in any
with emblem
location where the vehicle with such plate may be found. The Missouri Department of
Motorcycle/motortricycle with
3
Revenue will not issue plates that conflict with the regular license numbering system.
emblem and wheelchair symbol
YEAR
MAKE
MODEL
VIN NUMBER
VEHICLE PLATE WILL
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
BE ATTACHED TO
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE
FOURTH CHOICE
FIFTH CHOICE
SIXTH CHOICE
Description of what the
Description of what the
Description of what the
Description of what the
Description of what the
Description of what the
configuration above stands for.
configuration above stands for.
configuration above stands for.
configuration above stands for.
configuration above stands for.
configuration above stands for.
LICENSE OFFICE INFORMATION AND SIGNATURE (Must be completed by all applicants.)
STEP 4
IMPORTANT: These license plates will not be mailed. Indicate name of license office where plates are to be picked up.
I hereby certify under penalty of perjury that all information regarding this request is true and accurate
OFFICE
OFFICE NUMBER
and is made without intent to defraud and that all statutory requirements for personalized or special
__ __ __
license plates have been met. I also acknowledge that, if the requested configuration is already issued for
a vehicle I own, I must surrender those plates when I pick up the new plates bearing that configuration.
STREET
CITY
SIGNATURE OF OWNER OR APPLICANT
X
DOR-4601 (8-2012)
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