Fillable Form Vsa 10 - License Plate Application printable pdf download

VSA 10 (09/10/2013)

LICENSE PLATE APPLICATION

Purpose:

Use this form to request souvenir, standard, personalized or special license plates.

Instructions:

Review the Additional Information Section on the back of this form. Mail completed form, with the appropriate fees, to

DMV at the address above. Or, you may apply online at or at any DMV Customer Service Center

or DMV Select office.

APPLICATION TYPE (check one)

VEHICLE

VEHICLE LICENSE

SOUVENIR

TRANSFER EXISTING

LICENSE PLATES

PLATES - DISABLED

LICENSE PLATES

LICENSE PLATE TYPE REQUESTED (check one)

LIGHTHOUSE

STANDARD

(Blue and White)

HERITAGE

(Dogwood-Cardinal)

SCENIC

(Mountain To Seashore)

(Autumn)

(Patriot)

City

County ______________

COLLEGE: __________________________ Locality:

MILITARY

___________________________________

(No initials or abbreviations)

CLEAN FUEL _______ ____________ ___________

SPECIAL INTEREST: ______________________________________________________

(Organization Name - If organization has more than one license plate, specify design type)

Vehicle Year

Make

Model

(Review the Clean Fuel License Plates

section on the reverse side of this form.)

OTHER_______________________________

(Note: some plates require certification)

(Any plate not listed above)

PERSONALIZED LICENSE PLATES: To request a personalized vehicle or

souvenir plate, review the Personalized License Plates Policy on the reverse

side of this form. Check this box and enter your choices below.

PERSONALIZED LICENSE PLATE CHOICES

DMV USE ONLY

AVAILABLE CHOICE

FEE

APPLICANT INFORMATION

DAYTIME TELEPHONE NUMBER

OWNER'S NAME (last)

(first)

(mi)

(

)

CO-OWNER'S NAME (last)

(first)

(mi)

DAYTIME TELEPHONE NUMBER

(

)

CURRENT MAILING ADDRESS

CITY

ZIP CODE

STATE

CURRENT PLATE NUMBER

PLATE TYPE

PLATE EXPIRATION DATE

VEHICLE TITLE NUMBER

VEHICLE IDENTIFICATION NUMBER

IF PAYING BY CREDIT CARD, ENTER CARD NUMBER AND EXPIRATION DATE

CERTIFICATION/SIGNATURES

I/We certify that (Check only ONE box)

This vehicle is insured with liability coverage by a company licensed to do business in Virginia. Coverage must be in effect at the time of application and must

remain in effect as long as the vehicle is registered, even if the vehicle is not driven or is inoperable.

This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. This fee provides NO insurance coverage.

Failure to comply with Virginia's insurance requirements will result in suspension of your driver's license and vehicle license plates.

I/We further certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that

the information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we

understand that knowingly making a false statement or representation on this form is a criminal violation.

For a corporation, an authorized representative must sign.

APPLICANT SIGNATURE

DATE

(mm/dd/yyyy)

CO-APPLICANT SIGNATURE

DATE

(mm/dd/yyyy)