Fillable Form Mv-411 - Emergency Services Custom Plates printable pdf download

New York State Department of Motor Vehicles

EMERGENCY SERVICES CUSTOM PLATES

In New York State, custom plates allow easy identification of vehicles owned by members of emergency services groups. They are

subject to the following conditions: your current registration must be in the name of the emergency services member except

for the two plate series listed below with an asterisk (*); only ONE set of plates may be issued to any one customer (except

for Water Rescue Team).

PLATE SERIES REQUESTED (required proof and initial fees are identified in parentheses):

Civil Air Patrol (PROOF: Valid Civil Air Patrol card – FEE: $43.00)

Emergency Medical Technician (PROOF: Copy of Health Department registration certificate – FEE: $43.00)

Emergency Medical Technician Paramedic (PROOF: Copy of Health Department Certificate AEMT4 – FEE: $43.00)

Ham Radio Operator (PROOF: Copy of FCC License – FEE: $23.00)

Volunteer Ambulance Service (PROOF: Letter from ambulance company certifying eligibility. Must be on ambulance

company letterhead – FEE: $33.00)

Volunteer Fire Fighter (PROOF: Letter from Fire Chief certifying eligibility - FEE: $33.00)

Water Rescue Team (PROOF: Copy of an official document that proves you are an active member of a Water Rescue

Team – FEE: $43.00, PERSONALIZED FEE: $68.00).

NOTE: To obtain custom plates in the series marked with an asterisk (

), the current registration must be in the

name of the member or spouse. Please call Custom Plates at the number at the bottom of this page if you need

the International Symbol of Access on your plate.

FILL IN INFORMATION BELOW (Please Print):

Last Name

First

M.I.

Date of Birth (Month/Day/Year)

Mailing Address (Include Street and No.)

Apt. No.

City

State

Zip Code

Signature (Sign Name in Full)

Date

Daytime Phone No. (Area Code)

(

)

Vehicle

Plate

Model

Make

Number

Year

Amount Enclosed

Payment Method:

Check

Money Order

MasterCard

Visa

American Express

Discover

__________________

Name (as it appears on credit card) ______________________________________________________

Card Account Number ____________________________________________ Expiration Date

________________________

__________________________________________________________________________

Authorized Signature

Please do not send cash! Make check or money order payable to Commissioner of Motor Vehicles. Please allow 4 to 6 weeks

for delivery. The annual renewal fee is: $25.00 for Civil Air Patrol, Emergency Medical Technician, Emergency Medical Technician

Paramedic and Water Rescue Team; $15.00 for Ambulance Service; and $5.00 for Ham Operators. There is no annual fee for

Volunteer Fire Fighter. These fees are in addition to your vehicle registration renewal fee.You will be billed for the plates every

two years when you renew your registration.

Return this completed form, the required proof and your payment to:

Department of Motor Vehicles, Custom Plates Unit, Room 231, 6 Empire State Plaza, Albany NY 12228.

NOTE:

Plates are not ordered until we receive ALL required documents and fees.

The next available number in the series will be assigned. You cannot choose your own standard plate number.

Falsifying documents will result in cancellation of the custom plates.

IMPORTANT: Making a false statement in any registration application, or in any proof or statements in connection with it, or

deceiving or substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic

Law, and may also result in the revocation or suspension of the registration and/or the applicant’s license, pursuant to

regulations established by the Commissioner.

If you have any questions, or need additional information, call 518-402-4838. --- ---

MV-411 (6/07)

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Form Mv-411 - Emergency Services Custom Plates

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