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

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MV-904SP (10-15)

ApplicAtiOn FOr SpEciAl

www dmv pa gov

OrgAniZAtiOn rEgiStrAtiOn plAtE

(PLEASE ALLOW 4-6 WEEKS FOR DELIVERY)

For Department Use Only

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

Home (

) _______________

or Bus. ID#

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 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

INDIANA UNIV. OF PA ALUMNI

TAG TYPE: B8

nAME OF OrgAniZAtiOn:

Indiana University of Pennsylvania

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

IUP Alumni Association

Street Address

City

State

Zip Code

880 School Street

Indiana

15705

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 $100 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 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.

APPLICANT’S SIGNATURE IN INK

DATE