Nys Fraternal Order Of Police - License Plate Program Application

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06/27/2012

NYS Fraternal Order of Police

License Plate Program

Mail to: NYS Fraternal Order of Police, 911 Police Plaza, Hicksville, NY 11801

ELIGIBILITY: You must be an ACTIVE me mber in NYSF OP residing in NY, S no more than three plates per member .

A copy of your Law Enforcement ID and VEHICLE REGISTRATION MUST BE SUBMITTED with the order form. The submission

of any false information may result in the prevention and/or revocation of your privilege to have FOP pla tes. Eligibility will be veriﬁed.

This is the only form that will be accepted when accompanied with applicant’s current registration, personal check or money order and the

General Consent for Release of Personal Information signed and notarized.

Please Print

Current Vehicle Plate #_______________Expires___________Vehicle Make: _________Model ______Year________

Name (as it appears on current registration)

Last_________________________ First____________________ Middle ____________ Date of Birth___ /____/____

Street_________________________________ County____________ Tel # (9am-4pm) (

)___________________

City________________________ State____ Zip________

Member No. ___________ Lodge No. ________________

Standard NYSFOP Plate as it appears here. Numbers letters will vary.

Cost: $100.00 ($40 of this initial cost will be retained by the organization

to be used for scholarship & administration). All annual renewals are handle

by the NYS Department of Vehicles.

as it appears above (without the FOP in vertical format), with any combination of numbers, letters

Personalized NYSFOP Plate

and blanks not to exceed 6 spaces. Cost: $131.25 ($40 of this cost will be retained by the organization to be used for scholarship

& administration. After the ﬁrst year, annual renewals are handle by the NYS Department of Vehicles. Enter up to three choices in

order of preference, put a period (.) on the line in the choice where you want the space. Allow 4-6 weeks for delivery.

choice ___ ___ ___ ___ ___ ___ 2

choice ___ ___ ___ ___ ___ ___ 3

choice ___ ___ ___ ___ ___ ___

For personalized plate combinations only.

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, including plates that have

already been issued.

1 Choice_____________________________________________________________

Choice_____________________________________________________________

I would like to order: _____Standard Plates $100.00,

_____ Personalized Plates $131.25

Payment Methods: Check or Money Order should be made payable to NYS Fraternal Order of Police

______________________________________________________________________________________________________

New York State Departme nt of Motor Vehicles

GENERAL CONSENT FOR RELEASE OF PERSONAL INFORMATION

I _________________________________________, authorize the New York State Department of Motor Vehicles to disclose or otherwise make available to

NYSFOP, my name, address, plate number and registration information during the time period in which I hold NYSFOP Member plates issued by DMV.

Motorist’s Signature _____________________________________________________________________________________

STATE OF_________________________________

COUNTY OF__________________________________

On this__________day of ________________________________ before me personally appeared_________________________________________________

)

(Month)

(Year)

to me known and who by being duly sworn, acknowledged to be person described in and who executed the foregoing consent and he/she duly acknowledged to

me that he/she executed the same.

______________________________________________________

Notary Public

If plates are to be used on a spouses vehicle, please complete:

Members Name: ________________________________Membership Number: _______________ Date: ___/___/___