220130 Special Plate VSA 10D Submission

VIN LAST 4 DIGITS of Vehicle VIN*
VEHICLE TITLE NUMBER*
OWNER'S FULL LEGAL NAME*
Owners Phone Number
Please enter a valid phone number.
Co-OWNER'S FULL LEGAL NAME
Co-Owners Phone Number
Please enter a valid phone number.
OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS*
OWNER'S CITY*
OWNER'S STATE*
OWNER'S ZIP CODE*
CURRENT PLATE NUMBER*
EXPIRATION DATE

MonthDayYear
Date
PLATE TYPE
DISABLED PLATE*

YesNo
PLATE CHOICE (be sure to select correct amount at checkout below)*

A. TRANSFER NUMBER ($10)B. NEW PERSONALIZED PLATE ($20)C. DO NOT PERSONALIZE ($10)
1st Choice Personalized (one digit per field - blanks OK)
1st - 1
1st - 2
1st - 3
1st - 4
1st - 5
1st - 6
2nd Choice Personalized (one digit per field - blanks OK)
2nd - 1
2nd - 2
2nd - 3
2nd - 4
2nd - 5
2nd - 6
3rd Choice Personalized (one digit per field - blanks OK)
3rd - 1
3rd - 2
3rd - 3
3rd - 4
3rd - 5
3rd - 6
4th Choice Personalized (one digit per field - blanks OK)
4th - 1
4th - 2
4th - 3
4th - 4
4th - 5
4th - 6
CERTIFICATION INSURANCE*

YES INSUREDNOT INSURED
Vehicle Owner Signature*

Clear
OWNER'S SIGNATURE DATE

MonthDayYear
Date
Vehicle Co-Owner Signature

Clear
CO-OWNER'S SIGNATURE DATE

MonthDayYear
Date
Email - For future announcements about plate status only*
example@example.com

Personalized $20 or Standard Plate for $10

Non Personalized Plate

(not including $.51 processing and credit card fees)

$10.00

LFC Personalized Plate

(not including $.91 processing and credit card fees)

$20.00

Total

$0.00

1st Choice Personalized (one digit per field - blanks OK)