Virginia > Statewide > Department Of Motor Vehicles
License Plate Application VSA 10 - Virginia
| License Plate Application Form. This is a Virginia form and can be used in Department Of Motor Vehicles Statewide . |
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VSA 10 (07/01/2011) LICENSE PLATE APPLICATION Purpose: Instructions: Use this form to request souvenir, standard, personalized or special license plates. Review the Additional Information Section on the back of this form. Mail completed form, with the appropriate fees, to DMV at the address above. 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 LICENSE PLATES VEHICLE LICENSE PLATES - DISABLED SOUVENIR LICENSE PLATES TRANSFER EXISTING LICENSE PLATES LICENSE PLATE TYPE REQUESTED (check one) STANDARD (Blue and White) SCENIC (Mountain To Seashore) SCENIC (Autumn) LIGHTHOUSE SCENIC (Patriot) City County ______________ MILITARY ___________________________________ (No initials or abbreviations) HERITAGE (Dogwood-Cardinal) COLLEGE: __________________________ Locality: (No initials or abbreviations) SPECIAL INTEREST: ______________________________________________________ (Organization Name - If organization has more than one license plate, specify design type) CLEAN FUEL _______ ____________ ___________ Vehicle Year Make Model OTHER_______________________________ (Note: some plates require certification) (Any plate not listed above) (Review the Clean Fuel License Plates section on the reverse side of this form.) 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. PERSONALIZED LICENSE PLATE CHOICES 1st 2nd 3rd 4th DMV USE ONLY AVAILABLE CHOICE FEE $ APPLICANT INFORMATION (first) (first) CITY PLATE TYPE (mi) (mi) STATE DAYTIME TELEPHONE NUMBER ( ) DAYTIME TELEPHONE NUMBER ( ) ZIP CODE PLATE EXPIRATION DATE VEHICLE IDENTIFICATION NUMBER OWNER'S NAME (last) CO-OWNER'S NAME (last) CURRENT MAILING ADDRESS CURRENT PLATE NUMBER VEHICLE TITLE 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. This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. This fee provides NO insurance coverage. 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 CO-APPLICANT SIGNATURE DATE (mm/dd/yyyy) DATE (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com VSA 10 (07/01/2011) 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. Personalization is an additional $10 annually. If you are renewing early, registration, special license plate, and personalized license plate fees will be prorated for the months remaining on your current vehicle registration. The Department of Motor Vehicles (DMV) will not honor a change of choice or refund after the order has been sent to the manufacturer. You may purchase samples of most special license plates. Personalized License Plates Policy All personalized character combinations are screened by DMV to ensure compliance with DMV's Personalized License Plate Policy. The combination of characters used to personalize a license plate must not violate DMV's Personalized License Plate Policy. DMV reserves the right to refuse and/or recall the issuance of any combination of objectionable characters if they, in anyway, carry a connotation that may be reasonably seen by a person viewing a license plate as 1) profane, obscene, or vulgar in nature, 2) sexually explicit or graphic, 3) excretory related, 4) describing intimate body parts or genitals, 5) describing drugs, drug culture or drug use, 6) condoning or encouraging violence, 7) describing illegal activities or illegal substances, 8) socially, racially, ethnically offensive, or disparaging. Personalized license plates require special handling; allow up to 60 days for delivery. Plates will be mailed directly to the applicant. Indicate your choices in order of preference. The maximum number of characters allowed on standard and scenic license plates is 7 ½. The maximum number of characters allowed on a heritage license plate is 6 ½. Six characters are allowed on all other license plates bearing logos. License plates with logos may sometimes accommodate an additional ½ space when personalized. A blank space and a dash are the only two characters that are ½ characters. An ampersand is considered a full character. Spaces, dashes, and ampersands cannot be used consecutively. Visit our website www.dmvNOW.com to create a plate or ask a DMV representative to determine availability. New Special Interest License Plate Development Information All application and refund inquiries should be directed to the sponsor who is maintaining and facilitating collection of the 450 pre-paid applications for new license plates through General Assembly authorization or currently under development. When the 450 pre-paid applications are being processed, personalized license plate and special license plate fees are not prorated. Your vehicle registration will not be renewed unless it is within two months of expiration. Should your vehicle registration require renewal, you will be billed by DMV for payment. The entire special license plate process could take up to two years depending on the direction of the sponsor. It generally takes about nine months to develop a new plate once the 450 pre-paid applications are collected. Clean Special Fuel License Plates Vehicles registered with clean special fuel license plates issued by DMV on or after July 1, 2011, are not eligible for occupancy exemptions in the I-95/395 or I-6
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