MV-904SP
(11-05)
APPLICATIONFOR
SPECIALTY
REGISTRATIONPLATE
F e e :$ 2 0 . 0 0
Commonwealthof Pennsylvania
Bureau of Motor Vehicles
SpecialTag Unit
P.O.Box 68293
Harrisburg,
PA 17106-8293
(PLUSANYADDITIONAL
FEESCHARGEDBY THEORGANIZATTON}
T I T L EN U M B E R
CURRENT
REG.PLATE#
A FORDEPARTMENT
USEONLY r,
CURRENT
EXPIRATION
I nctr | AuuKEsb - Must trst a street address, p.O Box # alone is not
acceotable.
In conjunction with replacemeni
lf additional registration cards are desired,the fee is .50 for each
$1
card.
TO BE COMPLETED BY ORGANIZATION
i Howmanyextraregistralion
I cardsdo youwant?
I
NAME OF ORGANIZATION:
AIDS R
520 West Fourth Street,
2 A Wi I I iamsport
To BEcoMPLETED
By oRGANtzATloN
oFFtctAL1""" rp"iEil*trrctionlEtii
I certifythat the individualnamedin sectionA is a memberin good standing
of the organizationtistedin sectfil]
NAME OF ORGANIZATIONOFFICIAL
|cERT|FYTHATALL|NFoRMAT|oNG|VENoNTH|SAPPL|cAT|oN|STRUEANDcoRREcTA
NAMEDORGANIZATION,
I WILL IMMEDIATELY
RETURNTHEREGISTRATION
PLATETO THEDEPARTMENT
OF TRANSPORTATION.
A P P L I C A N T ' SS I G N A T U R EI N I N K
GENERALINFORMATI6PP5@
This application,with SectionsA and D completedin full, must be returned
to the organizationofficial for submission to the
Department'No applications
sentdirectlyto the Department
by the organization
memberwill be processed.Alt applications
mustbe sent
to the Department
by the organization.
a
a
a
a
a
a
The applicantlisted in section A must be a registeredownerof the vehicle
as indicatedon the vehicle,sregistrationcredential. lf
the vehicleis a leasedvehicle,FormMV-11,"Ap[lication
for LesseeInformation",
mustbe completedand attached.(Note: FormMV-1Lis
available
on ourwebsiteat www.dmv.state.pa.us.)
Feerequiredwiththisapplication
is $20.00.The participating
organizations
maychargeadditional
feesto offsetthe costof plateproduction
anda contribution
to the organization.
Pleasecontactthe organization
representative
for correctpaymentmethod.Do NoT SENDCASH.
No specialtyplatewill be duplicated.lf yourplateis Iost,stolenor defacedyou
will needto reapplyfor a specialtyplateby completing
this
application
and submittingwith the appropriate
fees. should you need an immediaterepracement
plate,pleasecompleteand submit
"Application-forD-uplicate
FormMV-44,
Registration
plate,Renewaisl.t ", or weightclass
card, Replacement
of Registration
Sticker,,and
and submittinga fee of $7'5o A standardissued plate will be issuei
until
the
replacementspecialtyplate can be provrded.
(Note: FormMV-44is availableon ourwebsiteat www.dmv.state.pa.us.)
Requests
for specialtyregistration
platesare restricted
to passenger
vehicles,
trucksand motorhomes
wrtha registered
grossweightof not
moreihan 9,000lbs.Motorcyclesand trailersdo not qualifyfor specialty
registrationplates.
No REFUNDoF FEEwiil be issuedwhenappricant
cancersrequestafterorderis praced.
Whenthe applicantceasesto be a memberin the organization
as listedin section B, the registratron
pratemust be returnedto the
Department.
CompleteFormMV-44and submita fee of $Z.SO
for reissueof a regularseriesregistration
praie.
Specialty
platesare issuedin numberseguenceonryand maynot be personarized.
Toavoidpossibleproblems
withcitations
withyourold registration
plate,returnlt to: Department
of rransportation,
Bureauof MotorVehicles,
ReturnTag
pn tztoo-"assz
Unit,Po Box68597,Harrisburg,
aiteivor'naueieceived
yourspecial
plate.
organization
Pleaseallow4-6 weeksfor delivery.
lf applyingfor a Fraternalorder of Policeplate,the PAstate Lodge
seal and the pA state LodgeRecording
secretarysignaturemusrbe
affrxed
to thisapplication.