Form Mv-904sp - Application For Special Organization Registration Plate printable pdf download

Form Mv-904sp - Application For Special Organization Registration Plate

APPLICATION FOR SPECIAL

ORGANIZATION REGISTRATION PLATE

For Department Use Only

(PLEASE ALLOW 4-6 WEEKS FOR DELIVERY)

Bureau of Motor Vehicles • PO Box 68293 • Harrisburg, PA 17106-8293

VEHICLE DESCRIPTION AND APPLICANT INFORMATION -

Complete this section exactly as information appears on current registration card.

Title Number

Registration Plate Number

Expiration Date

Make of Vehicle

Year

Last Name (or Full Business Name)

First Name

Middle Name

PA DL/Photo ID#

Date of Birth

Telephone

or Bus. ID#

Home (

) _______________

Office (

) _______________

Zip Code

State

Street Address - Must list a street address. P.O Box # alone is not acceptable.

City

NOTE: In conjunction with replacement of your registration plate, you will receive one registration card. If additional registration cards are desired,

the fee is $2 for each card. Number of Duplicate Registration Cards Requested @ $2 each _________.

TO BE COMPLETED BY ORGANIZATION OFFICIAL

NAME OF ORGANIZATION:

Name of Organization, Chapter, Post, Lodge, Employer, etc.

Street Address

City

State

Zip Code

TO BE COMPLETED BY ORGANIZATION OFFICIAL - See special instructions on reverse.

I certify that the individual named in Section A is a member in good standing of the organization listed in Section B.

NAME OF ORGANIZATION OFFICIAL

TITLE

SIGNATURE

OPTIONAL PERSONALIZATION REQUEST -

NOTE: Additional $104 Fee Required.

Personalized registration plate choices may contain up to FIVE letters or numbers in combination. ONLY one hyphen or space is permitted, but not

both as part of the available spaces for personalization. No other special characters are available. Please use capital letters and print clearly. Additional

instructions and fees are listed on the reverse side of this application. NOTE: The shaded boxes contain a pre-printed letter configuration that is specific

to this registration plate and cannot be changed. These letters will appear on your personalized registration plate.

FIRST CHOICE

SECOND CHOICE

THIRD CHOICE

APPLICANT SIGNATURE

I certify that all information given on this application is TRUE and CORRECT and that when I cease to be a member of the above named organization, I

will immediately return the registration plate to PennDOT.

DATE

APPLICANT’S SIGNATURE IN INK