Form Hsmv 83043 - Application For Personalized License Plate

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STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES – DIVISION OF MOTORIST SERVICES

SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OFFICE

A P P L I C A T I O N F O R P E R S O N A L I Z E D L I C E N S E P L A T E

____________________________

INSTRUCTIONS ARE INDICATED ON REVERSE SIDE

Date of Application

PLEASE CONTACT YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE, LICENSE PLATE AGENCY

OR REFER TO THE REVERSE SIDE OF THIS FORM FOR FEE INFORMATION.

OWNER / APPLICANT IDENTIFICATION

Owner’s / Lessee’s Name:

Sex:

Date of Birth:

Street Address:

City:

State:

Zip:

Owner’s / Lessee’s D/L Number:

Owner’s / Lessee’s E-mail Address:

FEID#:

Co-Owner’s / Co-Lessee’s Name:

Sex:

Date of Birth:

Street Address:

City:

State:

Zip:

FEID#:

Co-Owner’s / Co-Lessee’s D/L Number:

Co-Owner’s / Co-Lessee’s E-mail Address:

VEHICLE INFORMATION

Current Decal Number:

Current License Plate Number:

Vehicle Type:

Title Number:

Vehicle Identification Number:

Vehicle Make:

Year:

Color:

Vehicle Weight:

CERTIFICATION

This is to certify that I am/we are the registered owner/lessee or co-owner/co-lessee of the motor vehicle referenced above.

I/we authorize my/our name, address, and renewal date to be provided to the organization sponsoring the specialty license plate selected.

Under penalties of perjury, I/we declare that I/we have read the foregoing document and that the facts stated in it are true.

Signature(s)

LICENSE PLATE SELECTION

(see reverse side for plate choices)

Enter the type of specialty license plate requested:

Specify the intended meaning/explanation for your

personalized license plate configuration choice

(nickname, initials, etc.):

Please Note:



Use no more than the number of characters authorized for the type of license plate you have requested

(including a space or hyphen, see reverse side).



For license plates with center graphic, allow two spaces for the logo or characters will cover the graphic design.

Centered Graphic

Left Graphic

Specialty Motorcycle

(7 characters, may also have an additional space or hyphen.

(5 characters)

(6 characters)

A regular motorcycle may have a Florida graphic.)

A B C

LOGO

1ST CHOICE

2ND CHOICE

3RD CHOICE

4TH CHOICE

INSTRUCTIONS

Carefully read all information on the front and back of this application before completing the application.

Complete the application form and submit it to your local county tax collector's office or license plate agency with the following items:

PROOF OF FLORIDA INSURANCE: Proof of personal injury protection (PIP) and property damage liability insurance (PDL) must be submitted in the form

of a card, policy, binder, certificate of insurance or affidavit.

A copy of your current registration certificate or renewal notice.

Remittance fees (payable to your county tax collector/license plate agency).

Please allow six to eight weeks for the manufacture and delivery of the license plate. The license plate will be delivered to your county tax collector's office or

license plate agency.

HSMV 83043 (Rev. 01/14) S