Form 2277 - Application For Driveaway Plate(S)/permit

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PLEASE MARK TRANSACTION TYPE BELOW:
MISSOURI DEPARTMENT OF REVENUE
PLATES
MOTOR VEHICLE BUREAU
FORM
NEW
RENEWAL
TRAILER DEALER
PO BOX 43, JEFFERSON CITY MO 65105-0043
2277
REPLACEMENT PLATES/TABS
ADDITIONAL PLATES
(573) 751-4469
PERMIT
APPLICATION FOR DRIVEAWAY PLATE(S)/PERMIT
(REV. 8-2012)
SINGLE TRIP PERMIT
INFORMATION
BEFORE COMPLETING THIS APPLICATION, PLEASE READ INFORMATION ON THE REVERSE SIDE.
DRIVEAWAY PLATE(S) — One-year registration — $48.00 (includes $3.50 processing fee) each or two-year registration — $96.00 (includes $7.00 processing fee) each. These plates
are limited to businesses other than motor vehicle dealers and may be used repeatedly by the licensee during the calendar year(s) of issuance. Trailer dealers may purchase one
driveaway plate to demonstrate a motor vehicle acquired by the dealer as a trade-in, if applicable. DRIVEAWAY PERMIT — Single trip only — $7.50 (includes $3.50 processing fee).
FULL NAME OF BUSINESS OWNER OR AUTHORIZED REPRESENTATIVE
LEGAL BUSINESS NAME (IF APPLICABLE)
RESIDENCE TELEPHONE NUMBER
DRIVER LICENSE NUMBER
DATE OF BIRTH
SECRETARY OF STATE CHARTER NUMBER
BUSINESS TELEPHONE NUMBER
TRAILER DEALER NUMBER
RESIDENT STREET ADDRESS
CITY
STATE
ZIP
BUSINESS STREET ADDRESS
CITY
STATE
ZIP
OWNER INFORMATION
(LIST ADDITIONAL OWNERS ON SEPARATE DOCUMENT)
LAST NAME
FIRST NAME
M. INITIAL
DRIVER LICENSE #
HOME PHONE #
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
NEW DRIVEAWAY PLATE REQUEST
NUMBER OF PLATES REQUESTED
PRICE PER PLATE
TOTAL
EXPIRATION YEAR
One Year - $48.00 (includes $3.50 processing fee)
Two Year - $96.00 (includes $3.50 processing fee)
DRIVEAWAY PLATE RENEWAL (List currently issued driveaway plates. Attach a separate sheet for additional plates.)
DRIVEAWAY PLATE NUMBER(S)
NUMBER OF PLATES REQUESTED
PRICE PER PLATE
One Year - $48.00 (includes $3.50 processing fee)
Two Year - $96.00 (includes $3.50 processing fee)
REPLACEMENT DRIVEAWAY PLATES
INCLUDE A REPLACEMENT PLATE/TAB/PROCESSING FEE OF $12.00 (INCLUDES $3.50 PROCESSING FEE) FOR EACH PLATE/TAB.
RECORD ITEM TO BE REPLACED
CHECK REASON FOR REPLACEMENT
NEW PLATE/TAB NUMBER (DEPT. USE ONLY)
PLATE NUMBER
TAB NUMBER
LOST
STOLEN
MUTILATED
DESTROYED
NEW PLATE
NEW TAB
APPLICANT CERTIFICATION OF USE
I certify that the plates or permit requested above will be used for a legitimate purpose as prescribed on the reverse side of this application. I further certify that the driveaway license plates
or permit being applied for will be used for the following specific purpose(s) (use separate sheet if necessary). __________________________________________________________
___________________________________________________________________________________________________________________________________________________
This is to certify that I have and will maintain, during the period of registration, financial responsibility with respect to each motor vehicle that I own, license, or operate on the streets or
highways. I also hereby certify that the information given herein is correct and the license plates or permit applied for will be used in accordance with the laws of Missouri. Any false
declaration is a crime under 575.060 RSMo. Any false declaration in this application is a violation of the law, and may be punished by fine or imprisonment or both.
You must include proof of financial responsibility sufficient to cover each motor vehicle which will be operated with driveaway plates or permit. You must include a photograph of
your business building and business sign (photographs must not exceed 8x10 inches and no smaller than 5x7 inches). The business phone number provided with the
business address must be a land line. The business phone number cannot be a cell phone.
SIGNATURE OF BUSINESS OWNER OR AGENT
PRINTED NAME
POSITION
DATE
NOTARY – NOTARIZATION IS REQUIRED FOR ALL APPLICATIONS
NOTARY PUBLIC EMBOSSER OR
STATE
COUNTY (OR CITY OF ST. LOUIS)
BLACK INK RUBBER STAMP SEAL
SUBSCRIBED AND SWORN BEFORE ME, THIS
USE RUBBER STAMP IN CLEAR AREA BELOW.
DAY OF
YEAR
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
APPROVED BY
DATE
DEPARTMENT USE ONLY
DOR-2277 (8-2012)

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