Form Mv-904sp - Application For Special Organization Registration Plate
ADVERTISEMENT
1
2MV-904sP
(9-14)
pennsylvania
DEPARTMENT OF TRANSPORTATION
M
dmv
state
pa us
APPLICATTON FOR SPECIAL
ORGANIZATION REGISTRATION PLATE
(PLEASE ALLOW 4-6
WEEKS FOR
DEL|VERY)
Fot Deprrilment
Use
Bureau
ol
l\,ilotor
Vehicles
.
PO
Box
68293
.
Only
PA 17106-8293
(complete this section exactly as information appears on current registration
card.)
Last Name (or Full Business
Name)
First
Name
Middle
Name
pA DL/photo lD#
or
Date of
Birth
StreetAddress
-
Must list a streel address.
pO
Box
# alone
is
not
acceDtable.
NoTE:
In
conjunction with replacement of your
plate, you
will
receive
one registration card. lf additional registriltion cards are desired,
the
fee is
$1.50
for
each
card. Number
of
Dupricate
Registration
cards
Requested
@
$r,so
each
_,
BY ORGANIZATION
OFF
NAME
oF oRGANIz/\rlotN:
MISERICORDIA UNIVERSIT!
TAG T)'PE: Et)
Name of Organization, Chapter, post, Lodge, gmptoyer,
etc
OFFICIAL
(See
special instructions on
,"u"r""J
I
certify
that
the individual named in
Section A is
a member
in good
standing
of
the organization listed in Sectign
B.
REQUEST
(NOTE:
Additionat $too
ree
nequireo.y
Personalized registration
plate_choices
may contain up to FIVE letters
or
numbers in
combination.
oNLy
one lryphen or space
ir;
permitted,
bur
nor
both'
(lf no hyphen
or
space is requested, one
block
will
remain
blank.)
No other special
characters
are ava
llble.
please
print
clearly. Additional
instructions
and
fees are listed on the reverse side of this application.
NoTE:
The pre-printed, shaded, stacked
boxes
are
characrers
specific
to
this
registration plate and cannot
be chanqed.
v
U
v
tl
v
U
I
certify that all information given on this application
is
TRUE
AND
CORRECT and that
when
I
cease
to
be a menrber of
the
above rramed organization,
I
will immediately return the registration plate
to
pENNDOT.
APPLICANT'S SIGNATURE IN
INK
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