Blank Virginia License Plate 2017

Vehicle assessment standards were set by the Virginia Department of Environmental Quality DEQ and adopted by DMV to ensure that only the cleanest vehicles are eligible for clean special fuel license plates. Not all vehicles qualify for the clean special fuel license plate. For a list of qualifying vehicles visit our website at www. DMV USE ONLY AVAILABLE CHOICE 1st 2nd 3rd 4th FEE APPLICANT INFORMATION OWNER S NAME last CITY DAYTIME TELEPHONE NUMBER mi first CURRENT MAILING ADDRESS CURRENT PLATE NUMBER PLATE TYPE VEHICLE TITLE NUMBER ZIP CODE STATE PLATE EXPIRATION DATE VEHICLE IDENTIFICATION NUMBER IF PAYING BY CREDIT CARD ENTER CARD NUMBER AND EXPIRATION DATE CERTIFICATION/SIGNATURES I/We certify that Check only ONE box This vehicle is insured with liability coverage by a company licensed to do business in Virginia. Coverage must be in effect at the time of application and must remain in effect as long as the vehicle is registered even if the vehicle is not driven or is inoperable. Failure to comply with Virginia s insurance requirements will result in suspension of your driver s license and vehicle license plates. Failure to comply with Virginia s insurance requirements will result in suspension of your driver s license and vehicle license plates. I/We further certify and affirm that all information presented in this form is true and correct that any documents I/we have presented to DMV are genuine and that the information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a false statement or representation on this form is a criminal violation. For a corporation an authorized representative must sign. APPLICANT SIGNATURE DATE mm/dd/yyyy CO-APPLICANT SIGNATURE page 2 ADDITIONAL INFORMATION Special license plate fees can be 10 15 or 25 annually or a one-time 10 25 or 50 fee based on the plate design in addition to the registration fees. Or you may apply online at www. dmvNOW.com or at any DMV Customer Service Center or DMV Select office. APPLICATION TYPE check one VEHICLE VEHICLE LICENSE PLATES - DISABLED SOUVENIR TRANSFER EXISTING LIGHTHOUSE STANDARD Blue and White SCENIC Mountain To Seashore SCENIC Autumn COLLEGE Locality No initials or abbreviations HERITAGE Dogwood-Cardinal SCENIC Patriot City County SPECIAL INTEREST Organization Name - If organization has more than one license plate specify design type MILITARY CLEAN FUEL Vehicle Year Make Model Review the Clean Fuel License Plates section on the reverse side of this form. OTHER Note some plates require certification Any plate not listed above PERSONALIZED LICENSE PLATES To request a personalized vehicle or souvenir plate review the Personalized License Plates Policy on the reverse side of this form. Check this box and enter your choices below. DMV USE ONLY AVAILABLE CHOICE 1st 2nd 3rd 4th FEE APPLICANT INFORMATION OWNER S NAME last CITY DAYTIME TELEPHONE NUMBER mi first CURRENT MAILING ADDRESS CURRENT PLATE NUMBER PLATE TYPE VEHICLE TITLE NUMBER ZIP CODE STATE PLATE EXPIRATION DATE VEHICLE IDENTIFICATION NUMBER IF PAYING BY CREDIT CARD ENTER CARD NUMBER AND EXPIRATION DATE CERTIFICATION/SIGNATURES I/We certify that Check only ONE box This vehicle is insured with liability coverage by a company licensed to do business in Virginia. Coverage must be in effect at the time of application and must remain in effect as long as the vehicle is registered even if the vehicle is not driven or is inoperable.