Form 5052 - Specialty License Plate Development Application
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MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE AND DRIVER LICENSING DIVISION
SPECIALTY LICENSE PLATES
FORM
PO BOX 569, JEFFERSON CITY MO 65105-0569
5052
(573) 526-3669
SPECIALTY LICENSE PLATE DEVELOPMENT APPLICATION
(REV. 05-2013)
THE FOLLOWING ITEMS MUST BE SUBMITTED WITH THIS COMPLETED FORM:
•
PROOF ORGANIZATION IS A NOT-FOR-PROFIT ENTITY (IS REGISTERED PURSUANT TO 501 (C) OF THE 1986 INTERNAL
REVENUE CODE AS AMENDED, OR EQUIVALENT LAW);
•
$5,000 APPLICATION FEE; AND
•
LIST OF 200 POTENTIAL LICENSE PLATE APPLICANTS.
SEE INSTRUCTIONS AND ADDITIONAL INFORMATION ON NEXT PAGE.
STEP 1
ORGANIZATION INFORMATION
NAME
DATE
__ __ /__ __ /__ __ __ __
ADDRESS
TELEPHONE NUMBER
(__ __ __)__ __ __-__ __ __ __
CITY
STATE
ZIP CODE
FAX NUMBER
(__ __ __)__ __ __-__ __ __ __
WEBSITE ADDRESS
E-MAIL ADDRESS
STEP 2
ORGANIZATION REPRESENTATIVE/POINT OF CONTACT INFORMATION
NAME
ADDRESS
TELEPHONE NUMBER
(__ __ __)__ __ __-__ __ __ __
CITY
STATE
ZIP CODE
FAX NUMBER
(__ __ __)__ __ __-__ __ __ __
ALTERNATIVE TELEPHONE NUMBER
E-MAIL ADDRESS
(__ __ __)__ __ __-__ __ __ __
LEGISLATIVE SPONSOR(S) INFORMATION – AT LEAST ONE CURRENT MEMBER OF THE MISSOURI GENERAL
STEP 3
ASSEMBLY MUST BE LISTED.
SPONSOR’S NAME
SPONSOR’S DISTRICT
ADDITIONAL SPONSOR’S NAME
SPONSOR’S DISTRICT
ADDITIONAL SPONSOR’S NAME
SPONSOR’S DISTRICT
ADDITIONAL SPONSOR’S NAME
SPONSOR’S DISTRICT
STEP 4
PROPOSED LICENSE PLATE INFORMATION
INDICATE BELOW THE ORGANIZATION’S NAME OR SLOGAN THAT IS TO APPEAR ON THE LICENSE PLATE.
DESCRIPTION OF PROPOSED LICENSE PLATE (E.G., BACKGROUND COLOR, FONT COLOR, COLOR OF “MISSOURI,” ETC.)
INCLUDE DRAFT COPY OF THE PROPOSED LICENSE PLATE DESIGN.
INDICATE THE CONTRIBUTION LEVEL(S) NECESSARY TO OBTAIN AN EMBLEM USE AUTHORIZATION STATEMENT FROM THE ORGANIZATION.
NONE
ANNUAL CONTRIBUTION AMOUNT: ____________
ONE-TIME CONTRIBUTION AMOUNT: ____________
BIENNIAL CONTRIBUTION AMOUNT: ____________
DOR-5052 (05-2013)
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