Form 4601 - Application For Missouri Military Personalized License Plates Page 2

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INSTRUCTIONS TO APPLICANT

Applications must be completed, signed, and submitted with the fee noted on the front of the application. The annual fee indicated on the application is in addition to

the regular registration fee set by law and is payable upon renewal. Depending on the type of license plates requested, additional documentation may be required

as noted below. Make check or money order (do not send cash) payable to the Missouri Department of Revenue and forward with this application to: MISSOURI

DEPARTMENT OF REVENUE, MOTOR VEHICLE BUREAU, PERSONALIZED LICENSE PLATE SECTION, PO BOX 569, 301 W HIGH ST, ROOM 370,

JEFFERSON CITY MO 65105-0569. The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds. If you

have questions regarding this application, call (573) 526-3669 or visit the department’s web site address at:

NOTE: YOU MUST RENEW YOUR PERSONALIZED MILITARY LICENSE PLATES WITHIN 60 DAYS OF EXPIRATION TO ENSURE THE MILITARY

PERSONALIZED PLATES ARE HELD IN YOUR NAME.

Fill in the name exactly as it is shown on the title of the vehicle to which you intend to register this license plate. Fill in your current address, daytime

STEP 1:

telephone number, and license plate number that you currently have on the vehicle.

Check the category of license plate that belongs on the vehicle to which you intend to register this plate. Local truck plates are limited to a 50 mile

radius.You may add the Disabled Person symbol to any plates. You must also submit an original signed Physician’s Statement for Disabled Person’s License

Plates (DOR-1776) from an advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, or optometrist must be submitted

that states the disability is permanent. The physician’s statement is valid for 90 days after completion by an authorized medical professional.

Check the type of license plate you would like issued. Please note that some license plates require additional documentation and/or requirements

STEP 2:

which are noted below. Military license plates are issued only to those vehicles titled in Missouri.

AIR FORCE, ARMY, COAST GUARD, MARINE CORPS, MERCHANT MARINE, NATIONAL GUARD, AND NAVY PLATES: The applicant must submit a copy

of his or her current military ID card, or ONE of the seven (7) documents to show honorable discharge listed at the bottom of this page.

AIR MEDAL, BRONZE STAR, COMBAT ACTION BADGE, COMBAT ACTION RIBBON, COMBAT INFANTRYMAN, COMBAT MEDIC, DISTINGUISHED FLYING

CROSS, SILVER STAR, ARMED FORCES EXPEDITIONARY MEDAL, AND LEGION OF MERIT: The applicant must submit a copy of ONE of the seven (7)

documents listed at the bottom of this page, which must be properly completed, signed, and list the citation or decoration the applicant received that corresponds with

the type of plate being requested.

BRONZE STAR PLACARD: The applicant must meet the requirements listed above for Bronze Star plates. This placard allows the applicant to park his or her motor

vehicle, weighing not more than six thousand (6,000) pounds, without charge, in a metered parking space if approved by the local authority’s governing body.

CIVIL AIR PATROL PLATES: The applicant must submit a $15.00 (minimum) original Emblem Use Authorization Statement from the organization.

CONGRESSIONAL MEDAL OF HONOR PLATES: The applicant must submit a letter from the United States Department of Veteran Affairs verifying the

applicant was awarded the Congressional Medal of Honor.

DISABLED VETERAN PLATES: The applicant must submit a statement from the United States Department of Veteran Affairs no more than six months old

stating their disability is service connected. If requesting the wheelchair accessibility symbol, the applicant must also submit an original signed Physician’s

Statement for Disabled Person License Plates (DOR-1776) from an advance practice registered nurse, licensed physician, chiropractor, physician’s assistant,

podiatrist, or optometrist must be submitted that states the disability is permanent. The physician’s statement is valid for 90 days after completion by an authorized

medical professional. Limited to one set per owner.

FORMER POW PLATES: The applicant must submit a copy of former POW membership card, or a statement from the United States Department of Veterans Affairs

or the United States Department of Defense, or ONE of the seven (7) documents as listed at the bottom of this page stating that he or she is a former prisoner of war.

GULF WAR (DESERT STORM OR SHIELD), KOREAN WAR, OPERATION ENDURING FREEDOM, OPERATION IRAQI FREEDOM, OPERATION NOBLE

EAGLE, VIETNAM VETERAN, AND WORLD WAR II PLATES: The applicant must submit ONE of the seven (7) documents listed at the bottom of this page, which

must be properly completed, signed, show honorable discharge, and list the citations or decorations he or she received for serving in the designated war or conflict.

MARINE CORPS LEAGUE PLATES: The applicant must submit a copy of Marine Corps League membership card verifying he or she is currently a member in

good standing of the Marine Corps League.

NAVY CROSS: The applicant must submit a copy of his or her Certificate of Release or Discharge from Active Duty (Form DD214) or Correction to Form DD214

(Form DD215) verifying the applicant received the Navy Cross decoration.

PEARL HARBOR SURVIVOR PLATES: The applicant must submit ONE of the following:

1. A copy of his or her discharge papers issued by the United States Armed Forces verifying that he or she served in the United States Armed Forces on

December 7, 1941, and was stationed on the Hawaiian Island of Oahu or other related military installation during the enemy attack;

2. Verification from the United States Armed Forces that he or she is a Pearl Harbor Survivor; or

3. A copy of the identification card issued by the Pearl Harbor Association, Inc. verifying he or she is a Peal Harbor Survivor.

PURPLE HEART PLATES: The applicant must submit a copy of ONE of the seven (7) documents listed at the bottom of this page, which must be properly

completed, signed, and list the Purple Heart as one of the citations or decorations the applicant received, or a copy of Military Order of the Purple Heart

membership card. The $15.00 fee is not required for the initial set of Purple Heart plates, however it is required for any additional sets of Purple Heart Plates

RETIRED MILITARY PLATES: The applicant must submit proof of retired status from a particular branch of the United States Armed Forces.

SOME GAVE ALL PLATES: The applicant who has had an immediate family member die in the line of duty while serving in the United States Armed Forces.

The applicant must submit a $25.00 (minimum) original Emblem Use Authorization Statement from the Veterans of Foreign Wars, or the Department of Revenue.

VETERANS OF FOREIGN WARS (VFW) PLATES: The applicant must submit a $25.00 (minimum) original Emblem Use Authorization Statement from the organization.

WARTIME DISABLED PLATES: You must submit a copy of your Disabled American Veteran (DAV) membership identification card and a copy of a current photo

identification card with this application.

ACCEPTABLE DOCUMENTATION AS NOTED ABOVE INCLUDES:

1. Enlisted Record and Report of Separation (Form WD AGO 53-55);

5. Official Discharge Order from the United States Armed Forces;

2. General Orders;

6. Report of Separation and Record of Service (Form NGB 22); or

3. Certificate of Release or Discharge from Active Duty (Form DD214);

7. Current Military ID Card

4. Correction to Form DD214 (Form DD215);

Indicate more than one personalized license plate choice. You may use a combination of letters and numbers. Please print clearly using all capital letters.

STEP 3:

Signs and symbols cannot be used except for one space, one dash, or one apostrophe. Space limitations are noted on the front of the application.

Please print capital letters and numbers as follows:

0 2 3 5 6 7 8 9

A B C D E F G H J K L M N

R S T U V W X Y Z

Indicate the license office name and number where license plates are to be picked up. The office name and number can be located at

STEP 4:

Sign the application.

You will receive a notification letter when your license plates have been sent to the license office you indicated on the front of this application.

Please allow up to several weeks after the license plates are ordered for the notification letter to arrive.

DOR-4601 (8-2012)