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Fillable Printable Mv Special Plates Application

Fillable Printable Mv Special Plates Application

Mv Special Plates Application

Mv Special Plates Application

MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5164
Phone: (651) 297-3166 TTY: (651) 282-6555
Web: dvs.dps.mn.gov
ApplicationforSpecialPlates
ASSIGNED PLATE #
ASSIGNED STICKER #
DEPUTY PAID STAMP
SECTION A
SPECIAL PLATES
Critical Habitat*
Support Our Troops*Motorcycle
Collegiate*
School Name:
Firefighter*Motorcycle
Remembering Victims of Impaired Drivers*
LimousineARO/CB
Van Pool
Volunteer Ambulance
Other:
VETERAN PLATES
World War II Veteran*
Korean Veteran*
Vietnam Veteran*Motorcycle
Persian Gulf Veteran*Motorcycle
MotorcycleIraq Veteran*
MotorcycleAfghanistan Veteran*
MotorcycleGWOT Veteran*
Expeditionary MedalService Medal
Combat Wounded Veteran*
Ex-POW Veteran*
"Proud To Be A Veteran"*Motorcycle
Laos (Allied Vet)*
Bronze Star Vet*Silver Star Vet*
Armed Forces Expeditionary Vet*
Korean Defense Service Vet*
Check one:
SECTION B
NEWDUPLICATETRANSFER
SECTION C
Describe below the vehicle on which special plates will be used.
SECTION D
MAKEYEARVEHICLE IDENTIFICATION NUMBERCURRENT PLATE #CURRENT STICKER #EXP. DATE
MONTH YEAR
SECTION E
When transferring special plates, describe below the vehicle on which the plates had been used.
MAKEYEARVEHICLE IDENTIFICATION NUMBERSPECIAL PLATE #EXP. DATE
MONTH YEAR
SECTION F
NAME OF APPLICANT
ADDITIONAL OWNER
List the contact information for the applicant.
SECTION G
If special plates must be replaced, please check one reason below:
LostDestroyedDefectiveNever ReceivedStolenDamaged
SECTION H
DRIVER'S LICENSE/ID NUMBERDATE OF BIRTH
DATE OF BIRTHDRIVER'S LICENSE/ID NUMBER
STREET ADDRESSCITYSTATEZIP CODE
NOTICE: Personalized plates are limited to 7 characters except for motorcycles, 1-ton pick-up trucks,
and RV's, which are limited to 6 characters (see instructions on back).
1st
2nd
3rd
REGISTRATION TAX
PLATE FEE
REPLACEMENT FEE
ARO/CB or
PERSONALIZATION FEE
PLATE TRANSFER FEE
CONTRIBUTION
STATE FILING FEE
TOTAL DUE
PS2010-18 Rev. 12/15
Explanation of choices:
NOTE: This MUST be completed or plates will not be issued.
List 3 personalized plates in order of preference: (Or your ARO/CB call letters)
-OVER-
Motorcycle
Ready Reserve
National Guard
VFW*American Legion*
Disabled American Veterans*
PERSONALIZED PLATES
MotorcyclePassenger
Motorized Bicycle
Vertical Motorcycle (4 char. limit)
CollectorStreet RodClassic
Pioneer
Classic Motorcycle
MILITARY PLATES
Membership Document Required
Note: The specific plate within one of the special plate categories must also be checked in
addition to Special Disability Plates above.
DISABILITY PLATES
Special Disability Plates Standard Disability Plates
Select
one:
(Denoted by an asterisk*)
(Must submit a copy
of FCC license)
MotorcycleWoman Vet*
Pearl Harbor Survivor
Retired Firefighter*Motorcycle
MN Golf*
Motorcycle
Policy Expiration Date (mm/dd/yyyy)Policy NumberCompany Name
INSURANCE: MN Statute 169.78 Subd. 4 Every owner, when applying for vehicle registration, re-registration, or transfer of ownership, must
provide information showing that the vehicle is covered by an insurance policy. Required information consists of:
Print Form
PS2010-18 Rev. 12/15
Application for Special Plates
SECTION I
AMATEUR RADIO OPERATOR / CB RADIO
The subscriber hereto applies for special amateur radio or citizens band plates for the passenger automobile described above and declares that he/she holds an official amateur radio or
citizens band station license in good standing issued to him/her by the Federal Communications Commission.
SECTION L
SECTION M
I certify the special plates assigned to the described vehicle will be used only on that vehicle as long as it is in my possession. I will notify the department when
the Special Plates are transferred to another vehicle.
SECTION O
Except for certain uses permitted by federal and state laws, personal information contained in your application may not be disclosed
to anyone without your express consent. You may expressly consent to the disclosure of your personal information by writing to DVS.
SECTION P
IMPORTANT - PLEASE READ
DISABILITY LICENSE PLATES
Please list the disability parking certificate number issued for a PERMANENT
SECTION N
Disability: #
No further medical statement is necessary (Long-Term, Short-Term, & Temporary certificates do not qualify)
If you DO NOT have a parking certificate, you must complete an application for Disability Parking Certificate (PS2005) with the required Medical statement & signatures and attach
to this form. Only a permanent mobility impairment will qualify.
I certify I own or primarily operate the described vehicle and I meet one or more of the definitions for Physically Disabled Person defined in statute.
Driver's License / ID Number
Signature of Disabled Applicant
If the vehicle owner is the custodial parent or guardian of a permanently disabled minor or
legal ward list name and date of birth below:
CERTIFICATION OF EX-P.O.W. STATUS
I certify that the applicant was a member of the military forces of the United States who was captured, separated and incarcerated by an enemy of the United States during a period of
armed conflict.
Commissioner of MN Veteran's Affairs
RETIRED FIREFIGHTER VERIFICATION
A letter of authorization signed by the Fire Department Chief must be attached to the application for Retired Firefighter plate issuance.
"I certify that I was a member of the fire department identified below in good standing for at least 10 years and now retired"
Date
Signature
Department/Organization
(Volunteer Ambulance Attendant is defined by M.S. 144E.01, subd. 15 See Instructions)
"I certify that I am an active member of the organization for volunteer ambulance attendants identified below. I will immediately notify the Department of Public Safety upon the
termination of my membership in this department or organization."
VOLUNTEER AMBULANCE ATTENDANT VERIFICATION
SECTION J
Department/Organization
Date
SECTION K
FIREFIGHTER VERIFICATION
A letter of authorization signed by the Fire Department Chief must be attached to the application for Firefighter plate issuance.
"I certify that I am an active member of the fire department identified below. I will immediately notify the Department of Public Safety upon the termination of my membership in this
department or organization."
Department/Organization
Signature
Date
Signature
Date Federal Station License was issued
Is this the first or second set of ARO plates ordered?
2nd1st
ARO/CB Call Letters
APPLICANT'S SIGNATURE
X
1972 and older vehicles that are used for general transportation.
Vehicles registered in a collector class. Use this form for Personalized Collector Class Plates.
The following vehicles have the option of displaying one or two license plates:
Please check the desired option:
One PlateTwo Plates
PLATE #:
Personalized Collector Class: List plate # of vehicle applicant's name owned or leased for general transporation.
COLLECTOR / STREET ROD / CLASSIC MC
Vehicle used for general transportation that is owned or leased and registered in the name of owner/applicant listed below.
Application for Special Plates
INSTRUCTIONS FOR APPLICATION
Please Read Thoroughly
Sections A, B, D, F, and Pmust be completed if applying for any category of special plates.
NEW PERSONALIZED PLATES
Personalized plates are special plates issued to the owner of a motor vehicle for use only on that vehicle. Plates must have at least one letter but not more than
seven characters total (a character is an upper-case letter, space, hyphen, or number.); a personalized plate may not display all numbers. Motorcycle, Motorized
Bicycle (Moped), pickup trucks registered by gross weight, and recreational vehicle plates are limited to six characters. A vertical Motorcycle plate is limited to 4
characters and may not utilize a hyphen. One space or hyphen may be placed between adjoining characters (will be counted as a character, a space cannot be
the first character). A personalized plate that offends public morals or decency may not be issued. Personalized plates cannot duplicate other existing plates or
any plates in a numbering system used or reserved by the Driver and Vehicle Services Division.
The characters 1 (one) and I (the letter "I") and Ø (naval zero), 0 (zero) and O (oh) are deemed to be the same and may not be
duplicated to create new combinations (e.g. “TIM and “T1M” are the same).
When you transfer (sell) a motor vehicle, you may leave the plates on the transferred (sold) vehicle. You will lose the rights to those plates and the buyer of that
motor vehicle will assume the rights. Please submit a statement that the plates are to remain with the vehicle.
You may transfer the personalized plates to another motor vehicle registered in your name. You must complete another personalized plate application showing
the description of the vehicle on which the personalized plates will be displayed. It is your responsibility to obtain regular plates for the motor vehicle on which the
personalized plates were used.
If you are transferring the plates to a different class vehicle, (e.g., transfer from passenger class to gross weight class) new plates are required and must fit the
number of characters allowed for that new plate type.
TRANSFER OF PERSONALIZED PLATES
If you wish to retain the privilege of your combination you must keep current registration on the vehicle that the plates are displayed on as stated in M.S.168.12,
subd. 2a. If you fail to maintain registration, you may lose your rights to that combination.
If you do not have another vehicle to place your personalized plates on, you may submit a letter requesting an extension (not to exceed one year) of your rights to
that combination or you may lose your rights to that combination. All correspondence must be submitted to the Division at the address listed on the front of this
form.
RETENTION OF YOUR PERSONALIZED PLATES (Minnesota Rules section 7403.0950)
*OTHER Special Plates
This line in Section A exists to accommodate any special plate that is not represented on the form but has been authorized.
If the vehicle on which the special plates are now being used is sold, complete this application if you wish to transfer the special plates to another vehicle. It is
your responsibility to obtain regular plates for the vehicle on which the special plates were used. If the expiration month and year on your special plates do not
agree with the regular plates submitted, the special plates must be adjusted.
TRANSFER OF SPECIAL PLATES (Excluding Personalized and Disability Plates)
LIMOUSINE and COMMUTER VANPOOL
"Limousine" means an unmarked luxury passenger automobile that is not a van or station wagon and has a seating capacity of not more than 12 persons,
excluding the driver. MN Rules 8880.0100.
Commuter vanpool means a prearranged ride-sharing arrangement in which seven to 16 persons travel together on a regular basis in a commuter van to and
from their place of employment or to and from a transit stop authorized by a local transit authority.
Application for Special Plates
PS2010-18 Rev. 12/15
IN ADDITION, when:
Transferring special plates, complete SectionE.
Replacing special plates, complete Section G.
When applying for:
Personalized plates, complete SectionH. A statement that adequately explains the meaning is required.
ARO/CB plates, complete SectionI.
Limousine plates, a certificate of insurance is required. A limousine is an unmarked luxury passenger vehicle with a seating capacity of not more than
15 persons including the driver.
VolunteerAmbulance Attendant plates, complete Section J.
NOTE: M.S. 144E.01 Subd. 15. Volunteer ambulance attendant.
"Volunteer ambulance attendant" means a person who provides emergency medical services for a Minnesota licensed ambulance service without the
expectation of remuneration and who does not depend in any way upon the provision of these services for the person's livelihood. An individual may be
considered a volunteer ambulance attendant even though the individual receives an hourly stipend for each hour of actual service provided, except for
hours on standby alert, or other nominal fee, and even though the hourly stipend or other nominal fee is regarded as taxable income for purposes of
state or federal law, provided that the hourly stipend and other nominal fees do not exceed $6,000 annually.
Firefighter / Retired Firefighter (Sections K & L) plates, an authorization letter from the fire chief is required.
Ex-POW plates, Section M must be signed by the Minnesota Commissioner of Veteran Affairs.
Disability plates, complete SectionN and attach a Disability Parking Certificate application form if necessary.
Personalized Collector, Street Rod, or Classic Motorcycle plates indicate the plate number of another vehicle owned or leased in your name and
used for general transportation in SectionO.
IMPORTANT: If applying for standard collector class plates or the use of original plates do not use this form: a PS2000 must be completed in lieu of
the special plate application.
PS2010-18 Rev. 12/15
Application for Special Plates
CONTRIBUTION PLATES
Contribution fees are in addition to any plate fee and are not refundable.
“PROUD TO BE A VETERAN”: A one-time minimum contribution of $30 to benefit the WWII memorial fund is due with initial application. “Proud to be a Veteran”
plate contribution is due only at the time of initial application.
“SUPPORT OUR TROOPS”: The minimum annual contribution is $30. You may make an additional contribution by indicating the total amount in the space
provided on application.
CRITICAL HABITAT PLATES: The minimum annual contribution is $30. You may make an additional contribution by indicating the total amount in the space
provided on application. Indicate your design choice in the space provided on page one.
COLLEGIATE PLATES: The minimum annual contribution for collegiate license plates is $25 per year. You may make an additional contribution by indicating the
total amount in the space provided on application. Indicate your design choice in the space provided on page one. Please check with your institution of choice
regarding participation in the special plate program or dvs.dps.mn.gov.
Plate Contributions are collected at the time of initial application, and each time registration is renewed.
In order to prove eligibility, veteran applicants are required to present a copy of their separation papers (DD 214 or equivalent) at the time of application.
State law requires that these discharges be certified (bearing a raised impression of a seal or a statement attesting to their authenticity).
“Ex-POW” may have plates for one vehicle and must have certification from the commissioner of veterans’ affairs.
ELIGIBILITY REQUIREMENTS FOR VETERAN PLATES
DATES OF SERVICE AND ELIGIBILITY
WORLD WAR II: Served between DECEMBER 7, 1941 & DECEMBER
31, 1946
KOREA: Served between JUNE 27, 1950 & JANUARY 31, 1955
VIETNAM: Served between JULY 1, 1961 & JUNE 30, 1978
PERSIAN GULF: Served after August 1, 1990 during operation Desert
Storm, Desert Shield or any other military operation in the Persian Gulf.
IRAQ: Honorably discharged recipient of the Iraq Campaign Medal
AFGHANISTAN: Recipient of the Afghanistan Campaign Medal
GLOBAL WAR ON TERRORISM VETERAN (GWOT): Recipient of the
Global War on Terrorism Expeditionary Medal or the Global War on
Terrorism Service Medal. Please note which design is requested
LAOS (Allied Vet): Non-US Military who Served in the Laos War after
July 1, 1961, and before July 1, 1978. Certification required
SILVER STAR / BRONZE STAR
Applicant must provide dd214 or other documentation to show they have
been awarded the Corresponding Service Medal
COMBAT WOUNDED: Awarded the Purple Heart (May still be in active service)
“PEARL HARBOR SURVIVOR”: Stationed on the island of Oahu or offshore on
December 7, 1941 “Pearl Harbor Survivor” must have proof of eligibility for
membership in a Pearl Harbor survivor’s organization.
EX-POW: Must be certified by commissioner of veteran affairs.
MEDAL OF HONOR: Awarded the Medal of Honor
WOMAN Veteran: Honorably discharged veteran from any branch of the armed
services (available starting 01/01/2015)
“PROUD TO BE A VETERAN”: Honorably discharged from any branch of the
armed services.
Ready Reserve: Member or retired member of the United States Armed Forces
Ready Reserve
National Guard: Regularly enlisted, commissioned, or retired member of the
Minnesota National Guard
VFW / American Legion / DAV: Applicant provides membership card
KOREAN DEFENSE SERVICE/ ARMED FORCES EXPEDITIONARY:
Applicant must provide dd214 or other documentation to show they have been
awarded the Corresponding Service Medal
DISPOSAL OF PLATES: It is the responsibility of the applicant to properly dispose of any valid license plates assigned to the vehicle on which the special
license plates will be displayed when the plates have been received. For your convenience, these plates may be returned to a deputy registrar for recycling.
NOTICE: All data collected on a motor vehicle application is required by law. All disability information is considered private by law.
FEES:When returning this application by mail, the required fees, including filing fee must be included.
If you have further questions, contact the Driver & Vehicle Services Division at (651) 297-3166.
One set of disability license plates is allowed per owner or primary operator; An additional set of disability plates may be allowed by filling out the questionnaire
from the State Council on Disability and attaching it to the application for review. No additional information is needed if the additional plate request is for a
Motorcycle. Disability plates may be issued to a custodial parent or guardian of a permanently physically disabled minor (until age 18) or legal ward as defined in
section 524.5-102, subd 17.
DISABILITY PLATES
TRANSFER OF DISABILITY PLATES:If the vehicle on which the disability plates are now being used is sold, complete this application if you wish to
transfer the disability plates to another vehicle. It is your responsibility to obtain regular plates for the vehicle on which the disability plates were used. If the
expiration month and year on your disability plates do not agree with the regular plates submitted, the disability plates must be adjusted.
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