Form Mv-400ph - Request For Custom Empire Plates - Disabled Registrant Page 2
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3METHOD OF PAYMENT
PART 3
Please Do Not Send Cash! If paying by check or money order, please make it payable to the “Commissioner of Motor Vehicles”.
o
o
o
o
Payment Method:
Check
Money Order
Master Card
Visa
$ _______________________
Amount Enclosed
o
o
American Express
Discover
Name (as it appears on credit card) ______________________________________________________
Card Account Number ________________________________________________________ Expiration Date ________________________
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Authorized Signature
______________________________________________________________
If you have any questions, call (518) 402-4838 or visit us at: dmv.ny.gov
PART 4
REQUEST FOR CUSTOM EMPIRE PLATES FOR A DISABLED REGISTRANT
Custom plates are manufactured in most combinations of as many as six letters and/or numbers on a first-come, first-
served basis. The plate number you request must include at least one letter. Each plate will have a reproduction of the
International Symbol of Access on the right side of the plate. You may include a State silhouette anywhere except at
the beginning of the plate number by placing the @ symbol in the box where you want the silhouette to appear. Also,
if you want a space between any letters/numbers, place a period (.) in the box(es) where you want a space.
EXAMPLE
In this example, your choice of plate numbers, in order of your preference, are: My Car (with the State silhouette), Joe and Joseph.
First Choice:
Second Choice:
Third Choice:
MY CAR
JOE
JOSEPH
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
l
l
l
J
O
S
E
P
H
M
Y
@
C
A
R
J
O
E
To request your custom plate numbers, fill in your choices in the boxed area below. Use the following guidelines:
In the “Choice” boxes below, write the combination of letters and numbers (not more than six) you want on your plate. You may select, in
order of preference, as many as three different combinations of letters and numbers. For each choice, enter each letter or number exactly as you
want it to appear on the plate. Place a period (.) in any box where you want there to be a space on the plate. Place the @ symbol where you
want a State silhouette to appear.
Letters (A thru Z) and numbers (0 thru 9) can be entered in a box.
u
Other symbols, including dashes (-), may not be used. A period (.) in a box will be a blank space on the plate.
u
To distinguish between the letter “O” and a zero, put a slash thru a zero (0). The slash will not appear on the plate.
u
To distinguish between the letter “I” and the number “1”, use a capital “I”.
u
ORDER OF PREFERENCE (use letters and numbers only):
First Choice:
Second Choice:
Third Choice:
1
2
3
4
5
6
1
2
3
4
5
6
1
2
3
4
5
6
You must explain the meaning of your letter/number combination. DMV reserves the right to reject, recall or cancel any plate that is
deemed objectionable. This includes plates that have already been issued.
1st Choice ________________________________________________________________________________________________
2nd Choice ________________________________________________________________________________________________
3rd Choice ________________________________________________________________________________________________
...............................................................................................................................................................................................
DO NOT WRITE IN THIS SPACE - FOR DMV USE ONLY
PAGE 2 OF 3
MV-400PH (4/16)
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