Form 1716 - Application For Missouri Personalized And Special License Plates Page 2

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Regular personalized plates can be reserved and ordered at

plates.mo.gov

Applications must be completed, signed, and submitted with the fee noted on the front of the application. The annual fee indicated on the application is in addition

to the regular registration fee set by law and is payable upon renewal. Depending on the type of license plates requested, additional documentation may be

required as noted below. Make check or money order (do not send cash) payable to the Missouri Department of Revenue and forward with this application to the

address listed below. Note: The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.

You must renew your personalized license plates within 60 days of expiration to ensure the personalized plates are held in your name.

Fill in the name exactly as it is shown on the title of the vehicle to which you intend to register this license plate. Fill in your current address,

Step 1:

daytime telephone number, and license plate number that you currently have on the vehicle. Check the category of license plate that belongs

on the vehicle to which you intend to register this plate. Local truck plates are limited to a 50 mile radius.

Check the type of license plate you would like issued. Please note that some license plates require additional documentation and requirements

Step 2:

which are noted below.

838) constitutes a sworn statement that you hold an unrevoked

• Amateur Radio Plates: Your signature on an Amateur Radio Statement

(Form

and unexpired amateur radio license and that the call letters indicated on the front of this application are the official call letters issued by the Federal

Communications Commission (FCC). You must submit a Form 838 and a copy of your Federal Communications License with this application.

768) constitutes a sworn statement that the vehicle is a custom vehicle

• Custom Vehicle Plates: Your signature on a notarized General Affidavit

(Form

that is at least twenty-five years old and of a model year after 1948 or was manufactured to resemble a vehicle twenty-five years or older and of a

model year after 1948, has been altered from the manufacturer’s original design, or has an entire body constructed from nonoriginal materials, and is

being used for occasional transportation, exhibitions, club activities, parades, tours, and similar uses and will not be used for general daily

transportation. You must submit a Form 768 that contains the above statement with this application. Custom vehicle plates can only be transferred to

another custom vehicle.

•

Disabled Person Plates: A signed physician’s statement for disabled person’s license plates

(Form

1776) from an advance practice registered

nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, or optometrist must be submitted that states the disability is permanent.

The physician’s statement is valid for 90 days after completion by the physician.

• God Bless America Plates: A one time $10.00 contribution to the World War II Memorial Fund is required. You may submit the $10.00 contribution

with this application. If you previously made a contribution on or after August 28, 2002, you may submit a contribution receipt from the Missouri

Veteran’s Commission or verification of the contribution from the Missouri Department of Revenue with this application.

• Firefighter Plates: Your signature on a notarized General Affidavit (Form 768) constitutes a sworn statement that you are a director of a fire

protection district, or are compensated, partially compensated, or a volunteer member of any fire department, fire protection district, or voluntary fire

protection association in Missouri. You must submit a Form 768 with this application. You further affirm that if you resign, are removed, or

otherwise terminate association with the fire department, you will return your special license plates to the Missouri Department of Revenue within

15 days.

• Missouri 4-H, Jaycees, and Task Force 1 Plates: You must submit a copy of your current membership identification card with this application.

• Street Rod Plates: Your signature on a notarized General Affidavit (Form 768) constitutes a sworn statement that the vehicle is a street rod that

is older than 1949 or a vehicle manufactured after 1948 to resemble a vehicle manufactured before 1949, has been altered from the manufacturer’s

original design, or has an entire body constructed from nonoriginal materials, and is being used for occasional transportation, exhibitions, club

activities, parades, tours, and similar uses and will not be used for general daily transportation. You must submit a Form 768 that contains the

above statement with this application. Street rod plates can only be transferred to another street rod.

• An annual contribution to the organization and an EUAS is required for the following license plates: $15 for Emergency Medical Technician, Helping

Schools, Missouri Elks Association, and Paramedic; $25 for all specialty plates other than those listed in this paragraph; $30 for Missouri Bicycle

& Pedestrian Federation; and $35 for Kansas City Zoo, Missouri Botanical Garden, St. Louis Blues, St. Louis Cardinals, Kansas City Chiefs, and

St. Louis Zoo. The following plates do not require an annual contribution to the organization or an EUAS: Amateur Radio, Custom Vehicle, Disabled

Person, Firefighter, God Bless America, Missouri Jaycees, Missouri 4-H, Missouri Task Force 1, and Street Rod.

• Contribution to the organization may be collected by the Department of Revenue for the following license plates: Be an Organ Donor, Breast

Cancer Awareness, Children’s Trust Fund, Fight Terrorism, God Bless America, I have a dream Lewis and Clark, and Some Gave All.

Note: If applying for a two-year registration the EUAS amount must be doubled.

Step 3: (for all plates listed as “stock” skip this step.)

Indicate more than one personalized license plate choice. You may use a combination of letters

and numbers. Please print clearly using all capital letters. Signs and symbols cannot be used except for one space, one dash, or one apostrophe.

Space limitations are noted on the front of the application.

Please print capital letters and numbers as follows:

3 5 6 7 8 9

A B C D E F G H J K L M N

R S T U V W X Y Z

Indicate the license office name and number where license plates are to be picked up. The office name and number can be located at

Step 4:

Sign the application.

You will receive a notification letter when your license plates have been sent to the license office you indicated on the front of this application. Please

allow up to several weeks after the license plates are ordered for the notification letter to arrive.

Mail to:

Motor Vehicle Bureau

Phone: (573) 526-3669

Form 1716 (Revised 01-2014)

Personalized License Plate Section

E-mail:

mvbmail@dor.mo.gov

301 West High Street, Room 370

P.O. Box 569

Visit

Jefferson City, MO 65105-0569