Fillable Printable Form MV-411 - Emergency Services Custom Plates Application - New York

Form MV-411 - Emergency Services Custom Plates Application - New York

o Water Rescue Team (PROOF: Copy of an official document that proves you are an active member of a Water Rescue Team –

FEE: $53.75, PERSONALIZED FEE: $85.00).

Choice 1 ___ ___ ___ ___ ___ ___ Choice 2 ___ ___ ___ ___ ___ ___ Choice 3 ___ ___ ___ ___ ___ ___

You may provide up to three choices. DMV reserves the right to reject, recall or cancel any plate that is deemed objectionable. This includes

plates that have already been issued.

If the International Symbol of Access is required, only five spaces are allowed.

Payment Method: o Check o Money Order o MasterCard o Visa o American Express o Discover

Name (as it appears on credit card) ________________________________________________________________

Credit Card Number_______________________________________________ Expiration Date ____________________________________

Authorized Signature ç ______________________________________________________________________________________________

Please do not send cash! Make check or money order payable to Commissioner of Motor Vehicles. Please allow 4 to 6 weeks for delivery. The

annual renewal fee is: $31.25 for Civil Air Patrol, Emergency Medical Technician and Emergency Medical Technician Paramedic; $25.00 for Water

Rescue Team ($56.25 for Water Rescue Team personalized plates); $15.00 for Ambulance Service; and $6.25 for Ham Operators. There is no

annual fee for Volunteer Firefighter. These fees are in addition

to your vehicle registration renewal fee.You will be billed for the plates every two

years when you renew your registration.

EMERGENCY SERVICES CUSTOM PLATES

In New York State, custom plates allow easy identification of vehicles owned by members of emergency services groups. They are subject to the

following conditions: your current registration must be in the name of the emergency services member (except for Volunteer Ambulance Service

and Volunteer Firefighter - see “note” below); only ONE set of plates may be issued to any one customer (except for Water Rescue Team).

PLATE SERIES REQUESTED (required proof and initial fees are identified in parentheses):

FILL IN INFORMATION BELOW (Please Print):

o Civil Air Patrol (PROOF: Valid Civil Air Patrol card – FEE: $60.00)

o Emergency Medical Technician (PROOF: Copy of Health Department registration certificate – FEE: $60.00)

o Emergency Medical Technician Paramedic (PROOF: Copy of Health Department Certificate AEMT4 – FEE: $60.00)

o Ham Radio Operator (PROOF: Copy of FCC License – FEE: $35.00)

o Volunteer Ambulance Service (PROOF: Letter from ambulance company certifying eligibility. Must be on ambulance company letterhead

with original signature. FEE: $43.75)

o Volunteer Firefighter (PROOF: Letter from Fire Chief certifying eligibility. Must be on fire department letterhead with original signature.

FEE: $43.75

)

NOTE:

l Plates are not ordered until we receive ALL required documents and fees.

l The next available number in the series will be assigned. You cannot choose your own standard plate number.

l Falsifying documents will result in cancellation of the custom plates.

l Plates will be mailed to the address on the vehicle’s registration file. If you have moved and not updated your address

on your registration record, please complete the Change of Address form MV-232.

Last Name

Mailing Address (Include Street and No.) Apt. No.

Signature (Sign Name in Full)

First

City

M.I.

State Zip Code

Daytime Phone No. (Area Code)

( )

MV-411 (7/15)

Current Plate Number

Vehicle Model Year

Amount Enclosed

$________________

Vehicle Make

IMPORTANT: Making a false statement in any registration application, or in any proof or statements in connection with it, or deceiving or

substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in the

revocation or suspension of the registration and/or the applicant’s license, pursuant to regulations established by the Commissioner. The act

of renewing these plates shall constitute your certification that you remain eligible to continue holding these plates.

If you have any questions, or need additional information, call 518-402-4838 or visit www.dmv.ny.gov

Return this completed form, the required proof and your payment to:

Department of Motor Vehicles, Custom Plates Unit, PO Box 2775, Albany NY 12220.

Do your current plates have the

International Symbol of Access?

o Yes o No

If you need the International Symbol of Access on your new plates and you do not have it on your current plates,

you must also submit a completed form MV-664.1, which may be printed from the DMV website.

NOTE: To obtain custom plates in the two series listed below, the current registration must be in the name of the emergency services

member OR his/her spouse.

IMPORTANT: Only the Water Rescue Team plates may be personalized. Do not complete the personalization choices below if you have

chosen a different plate series.

Date

Date of Birth (Month/Day/Year)

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