Form 1716 - Application For Missouri Personalized And Special License Plates

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Missouri Department of Revenue

Application for Missouri Personalized

Form

1716

and Special License Plates

Any false statement in this application is a violation of the law and may be punished by fine or imprisonment or both.

Name must appear as shown on vehicle title

(Please check which category of license plate you need)

Owner’s Name

Passenger

Recreational Vehicle (motor home)

Beyond Local 6 Truck

Local 6 Truck (limited to a 50 mile radius)

Street, RR, or P.O. Box Number

Beyond Local 12 Truck

Local 12 Truck (limited to a 50 mile radius)

Beyond Local 18 Truck

Local 18 Truck (limited to a 50 mile radius)

City

State

Zip Code

Motorcycle/Motortricycle

Check here to add this symbol

to your plate.

Daytime Phone Number

Current Plate Number

(Form 1776, Physician’s Statement for Disabled Person’s License

Plates is required. See back for more information.)

(__ __ __)__ __ __-__ __ __ __

__ __ __ __ __ __

Submit fee shown below with this application.

Fraternal Order of Police ($15)

Missouri Stream Team Coalition ($15)

Friends of Arrow Rock ($15)

Missouri Task Force 1 ($15)

Regular Personalized ($15)

God Bless America ($15)

Missouri Travel Council ($15)

(Can be reserved at plates.mo.gov)

Greek Collegiate Organization ($15)

MKN Conference of Teamsters ($15)

Amateur Radio ($15)

_____________________________

MO-AG Businesses ($15)

American Heart Association ($15)

Hearing Impaired Kids Endowment Fund ($15)

Order of the Arrow ($15)

American Legion ($15)

Helping Schools ($15)

Paramedic ($15)

Be An Organ Donor ($15)

I Have A Dream ($15)

Prince Hall ($15)

Breast Cancer Awareness ($15)

I’m Pet Friendly ($15)

Professional Sports Team ($15)

Cave State ($15)

Jefferson National Parks Association ($15)

Children’s Trust Fund (Stock) ($15)

St. Louis Blues

St. Louis Cardinals

Kingdom of Calontir ($15)

Children’s Trust Fund ($15)

Kansas City Chiefs

Knights of Columbus ($15)

Choose Life ($15)

Rotary International ($15)

Lions Club (Stock) ($15)

Collegiate ($15)

Safari Club International ($15)

Lions Club ($15)

Name of College or University _____________

Search and Rescue ($15)

Masonic Grand Lodge ($15)

Columbia College ($15)

Shriners ($15)

Masters ($15)

Coroner’s Office ($15)

Special Olympics ($15)

Missouri 4-H ($15)

Custom Vehicle ($15)

St. Louis College of Pharmacy ($15)

Missouri Association of Realtors ($15)

Disabled Person ($15)

Street Rod ($15)

Missouri Bicycle & Pedestrian Federation ($15)

Don’t Tread on Me ($15)

Tribe of Mic-O-Say ($15)

Missouri Botanical Garden ($15)

Ducks Unlimited ($15)

Kansas City District

St. Joseph District

Missouri Conservation Heritage (Stock) ($15)

Eagle Scout ($15)

University of Missouri-Kansas City ($15)

Bird

Deer

Bald Eagle

Eastern Star ($15)

Wilson Creek Battlefield ($15)

Missouri Conservation Heritage ($15)

Emergency Medical Technician ($15)

Zoos ($15)

Kansas City

St. Louis

Bird

Deer

Bald Eagle

Fight Terrorism ($15)

Shuttle Bus ($15) — regular personalized

Missouri Elks Association ($15)

Firefighter (Stock) ($15)

Vanpool ($15) — regular personalized

Missouri Federation of Square & Round

Firefighter ($15)

Other _________________________

Dance Clubs ($15)

Former Legislator ($15)

Note: Please contact the Missouri Department

Missouri Jaycee (Stock) ($15)

Last Year Served _________

of Revenue for other specialty plates

Missouri Jaycee ($15)

Fraternal Order of Eagles ($15)

that may be available.

Missouri Remembers POW/MIA ($15)

For all plates listed as “Stock,” the Missouri Department of Revenue will select your license plate configuration.

Personalized plate choices (complete only if applying for personalized plates. Please include more than one choice.)

Please use all capital letters and show choices in order of preference. Regular personalized license plates may consist of no more than six characters plus a dash, a space, or an apostrophe.

Personalized plates displaying an emblem or wheelchair symbol may consist of no more than six characters or five characters plus a dash, a space, or an apostrophe. Personalized

plates displaying an emblem and wheelchair symbol are limited to four characters or three characters plus a dash, a space, or an apostrophe. Personalized motorcycle or motortricycle

plates may consist of no more than six characters or five characters plus a dash, space, or an apostrophe. Personalized motorcycle or motortricycle plates displaying an emblem or

wheelchair symbol may consist of no more than five characters or four characters plus a dash, space, or an apostrophe. Personalized motorcycle/motortricycle plates displaying

an emblem and wheelchair symbol may consist of no more than three characters or two characters plus a dash, space, or an apostrophe. The Missouri Department of Revenue

will not issue plates that contain any letters, numbers, or a combination of letters and numbers which are obscene, profane, patently offensive or contemptuous of a racial or ethnic

group, offensive to good taste or decency, or would present an unreasonable danger to the health or safety of the applicant, of other users of streets and highways, or of the public

in any location where the vehicle with such plate may be found. The Missouri Department of Revenue will not issue plates that conflict with the regular license numbering system.

Year

Make

Model

VIN Number

Vehicle Plate Will

__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Be Attached To

First Choice

Second Choice

Third Choice

Fourth Choice

Fifth Choice