Form 1716 - Application For Missouri Personalized And Special License Plates

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MISSOURI DEPARTMENT OF REVENUE
SEE INSTRUCTIONS ON REVERSE
MOTOR VEHICLE BUREAU
FORM
PO BOX 569, JEFFERSON CITY MO 65105-0569 (573) 526-3669
1716
ANY FALSE STATEMENT IN THIS APPLICATION IS
APPLICATION FOR MISSOURI
A VIOLATION OF THE LAW AND MAY BE PUNISHED
PERSONALIZED AND SPECIAL LICENSE PLATES
(REV. 07-2013)
BY FINE OR IMPRISONMENT OR BOTH.
STEP 1
STEP 1
NAME MUST APPEAR AS SHOWN ON VEHICLE TITLE
(PLEASE CHECK WHICH CATEGORY OF LICENSE PLATE YOU NEED)
OWNER’S NAME
Passenger
Recreational Vehicle (motor home)
Beyond Local 6 Truck
Local 6 Truck (limited to a 50 mile radius)
STREET, RR, OR P.O. BOX NUMBER
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)
CITY, STATE, ZIP CODE
Motorcycle/Motortricycle
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.
Fraternal Order of Police ($15)
Missouri Remembers POW/MIA ($15)
Friends of Arrow Rock ($15)
Missouri Stream Team Coalition ($15)
Regular Personalized ($15)
(Can be reserved at plates.mo.gov)
God Bless America ($15)
Missouri Task Force 1 ($15)
Amateur Radio ($15)
Greek Collegiate Organization ($15)
Missouri Travel Council ($15)
_____________________________
American Heart Association ($15)
MKN Conference of Teamsters ($15)
American Legion ($15)
Hearing Impaired Kids Endowment Fund ($15)
MO-AG Businesses ($15)
Be An Organ Donor ($15)
Helping Schools ($15)
Order of the Arrow ($15)
Breast Cancer Awareness ($15)
I Have A Dream ($15)
Paramedic ($15)
I’m Pet Friendly ($15)
Cave State ($15)
Prince Hall ($15)
Children’s Trust Fund (Stock) ($15)
Jefferson National Parks Association ($15)
Professional Sports Team ($15)
Children’s Trust Fund ($15)
Kingdom of Calontir ($15)
St. Louis Blues
St. Louis Cardinals
Choose Life ($15)
Knights of Columbus ($15)
Kansas City Chiefs
Collegiate ($15)
Lions Club (Stock) ($15)
Rotary International ($15)
Lions Club ($15)
Name of College or University ___________
Safari Club International ($15)
Columbia College ($15)
Masonic Grand Lodge ($15)
Search and Rescue ($15)
Coroner’s Office ($15)
Masters ($15)
Shriners ($15)
Custom Vehicle ($15)
Missouri 4-H ($15)
Special Olympics ($15)
Disabled Person ($15)
Missouri Association of Realtors ($15)
St. Louis College of Pharmacy ($15)
Missouri Bicycle & Pedestrian Federation ($15)
Don’t Tread on Me ($15)
Street Rod ($15)
Ducks Unlimited ($15)
Missouri Botanical Garden ($15)
Tribe of Mic-O-Say ($15)
Eagle Scout ($15)
Missouri Conservation Heritage (Stock) ($15)
Kansas City District
St. Joseph District
Eastern Star ($15)
Bird
Deer
Bald Eagle
Wilson Creek Battlefield ($15)
Missouri Conservation Heritage ($15)
Emergency Medical Technician ($15)
Zoos ($15)
Kansas City
St. Louis
Fight Terrorism ($15)
Bird
Deer
Bald Eagle
Shuttle Bus ($15) — regular personalized
Firefighter (Stock) ($15)
Missouri Elks Association ($15)
Vanpool ($15) — regular personalized
Firefighter ($15)
Missouri Federation of Square & Round
Other _________________________
Former Legislator ($15)
Dance Clubs ($15)
Note: Please contact the Missouri Department of
Missouri Jaycee (Stock) ($15)
Last Year Served _________
Revenue for other specialty plates that may be
Fraternal Order of Eagles ($15)
Missouri Jaycee ($15)
available.
For all plates listed as “Stock,” the Missouri Department of Revenue will select your license plate configuration.
STEP 3
PERSONALIZED PLATE CHOICES (Complete only if applying for personalized plates. Please include more than one choice.)
PLEASE USE ALL CAPITAL LETTERS AND SHOW CHOICES IN ORDER OF PREFERENCE. Regular personalized license plates may consist of no more than six characters plus a dash, a space, or an apostrophe.
Personalized plates displaying an emblem or wheelchair symbol may consist of no more than six characters or five characters plus a dash, a space, or an apostrophe. Personalized plates displaying an emblem and
wheelchair symbol are limited to four characters or three characters plus a dash, a space, or an apostrophe. Personalized motorcycle/motortricycle plates may consist of no more than six characters or five characters
plus a dash, space, or an apostrophe. Personalized motorcycle/motortricycle plates displaying an emblem or wheelchair symbol may consist of no more than five characters or four characters plus a dash, space,
or an apostrophe. Personalized motorcycle/motortricycle plates displaying an emblem and wheelchair symbol may consist of no more than three characters or two characters plus a dash, space, or an apostrophe.
The Missouri Department of Revenue will not issue plates that contain any letters, numbers, or a combination of letters and numbers which are obscene, profane, patently offensive or contemptuous of a racial or
ethnic group, offensive to good taste or decency, or would present an unreasonable danger to the health or safety of the applicant, of other users of streets and highways, or of the public in any location where the
vehicle with such plate may be found. The Missouri Department of Revenue will not issue plates that conflict with the regular license numbering system.
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 configuration
Description of what the configuration
Description of what the configuration
Description of what the configuration
Description of what the configuration
Description of what the configuration
above stands for.
above stands for.
above stands for.
above stands for.
above stands for.
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.
OFFICE
OFFICE NUMBER
I hereby certify under penalty of perjury that all information regarding this request is true and accurate 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.
SIGNATURE OF OWNER OR APPLICANT
STREET
CITY
X
DOR-1716 (07-2013)

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