Form 1716 - Application For Missouri Personalized And Special License Plates Page 2
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2REGULAR PERSONALIZED PLATES CAN BE RESERVED AND ORDERED AT PLATES.MO.GOV
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. If you have questions, call (573) 526-3669.
Or visit the department’s web site at Note: The Missouri Department of Revenue may electronically resubmit checks returned
for insufficient or uncollected funds.
NOTE: YOU MUST RENEW YOUR PERSONALIZED LICENSE PLATES WITHIN 60 DAYS OF EXPIRATION TO ENSURE THE
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
STEP 1:
address, daytime 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.
Check the type of license plate you would like issued. Please note that some license plates require additional documentation and/or
STEP 2:
requirements which are noted below.
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AMATEUR RADIO PLATES: Your signature on an Amateur Radio Statement (DOR-838) constitutes a sworn statement that you hold an
unrevoked and unexpired amateur radio license and that the call letters indicated on the front of this application are the official call letters
issued by the FCC. You must submit a DOR-838 and a copy of your Federal Communications License with this application.
CUSTOM VEHICLE PLATES: Your signature on a notarized General Affidavit (DOR-768) constitutes a sworn statement that the vehicle is
•
a custom vehicle that is at least twenty-five years old and of a model year after 1948 or was manufactured to resemble a vehicle twenty-five
years or older and of a model year after 1948, has been altered from the manufacturer’s original design, or has an entire body constructed
from nonoriginal materials, AND is being used for occasional transportation, exhibitions, club activities, parades, tours, and similar uses and
will not be used for general daily transportation. You must submit a DOR-768 that contains the above statement with this application. Custom
vehicle plates can only be transferred to another custom vehicle.
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DISABLED PERSON PLATES: A 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 the physician.
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GOD BLESS AMERICA PLATES: A one time $10.00 contribution to the World War II Memorial Fund is required. You may submit the $10.00
contribution with this application. If you previously made a contribution on or after August 28, 2002, you may submit a contribution receipt
from the Missouri Veteran’s Commission or verification of the contribution from the Missouri Department of Revenue with this application.
FIREFIGHTER PLATES: Your signature on a notarized General Affidavit (DOR-768) constitutes a sworn statement that you are a director of
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a fire protection district, or are compensated, partially compensated, or a volunteer member of any fire department, fire protection district, or
voluntary fire protection association in Missouri. You must submit a DOR-768 with this application. You further affirm that if you resign, are
removed, or otherwise terminate association with the fire department, you will return your special license plates to the Missouri Department
of Revenue within 15 days.
MISSOURI 4-H, JAYCEES, AND TASK FORCE 1 PLATES: You must submit a copy of your current membership identification card with
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this application.
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STREET ROD PLATES: Your signature on a notarized General Affidavit (DOR-768) constitutes a sworn statement that the vehicle is a street
rod that is older than 1949 or a vehicle manufactured after 1948 to resemble a vehicle manufactured before 1949, has been altered from the
manufacturer’s original design, or has an entire body constructed from nonoriginal materials, AND is being used for occasional transportation,
exhibitions, club activities, parades, tours, and similar uses and will not be used for general daily transportation. You must submit a DOR-768
that contains the above statement with this application. Street rod plates can only be transferred to another street rod.
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An annual contribution to the organization and an Emblem Use Authorization Statement (EUAS) is required for the following license plates:
$15 for Emergency Medical Technician, Helping Schools, Missouri Elks Association, and Paramedic; $25 for all specialty plates other than
those listed in this paragraph; $30 for Missouri Bicycle & Pedestrian Federation; and $35 for Kansas City Zoo, Missouri Botanical Garden,
St Louis Blues, St Louis Cardinals, Kansas City Chiefs, and St Louis Zoo. The following plates do not require an annual contribution to the
organization or an EUAS: Amateur Radio, Custom Vehicle, Disabled Person, Firefighter, God Bless America, Missouri Jaycees, Missouri 4H,
Missouri Task Force I, and Street Rod.
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Contribution to the organization may be collected by the Department of Revenue for the following license plates: Be An Organ Donor,
Breast Cancer Awareness, Children’s Trust Fund, Fight Terrorism, God Bless America, I Have A Dream Lewis and Clark, and Some Gave All.
Note: If applying for a two-year registration the EUAS amount must be doubled.
STEP 3: (For all plates listed as “Stock” skip this step.)
Indicate more than one personalized license plate choice. You may use a
combination of letters and numbers. Please print clearly using all capital letters. 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:
2
0
3 5 6 7 8 9
A B C D E F G H J K L M N
O
P
Q
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
STEP 4:
located at 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.
Visit dor.mo.gov/howdoi/vanity.php for more information
DOR-1716 (07-2013)
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