OMB Approval No. 1405 0072
Expires 03-31-2006
Estimate Burden 30 minutes*
SEE INSTRUCTIONS ON REVERSE
APPLICATION FOR REGISTRATION (MISSION VEHICLE)
U.S. Department of State
OFFICE OF FOREIGN MISSIONS
DIPLOMATIC MOTOR VEHICLE OFFICE
FOR OFFICE USE ONLY
Do Not Write
in this space
COUNTRY MISSION TYPE (Embassy, Consulate, UN, OAS, Other)
ADDRESS (No., Street, Apt., City, State, Zip Code)
PRINCIPAL DRIVER NAME
(SURNAME)
(First)
(MI)
I.D. NUMBER
PRINCIPAL USER NAME (SURNAME) (First)
(MI)
I.D. NUMBER
STATUS OF PRINCIPAL USER (Check One)
DIPLOMATIC CONSULAR
ADMINISTRATIVE/
TECHNICAL
SERVICE STAFF EMPLOYEE DEPENDENT
ADDRESS WHERE VEHICLE IS PRINCIPALLY GARAGED (No., Street, City, State, Zip)
VEHICLE IDENTIFICATION NUMBER MAKE MODEL
BODY
LEIN HOLDER/LEGAL OWNER (Name in Full) If the registered owner is the legal owner write NONE.
YEAR WEIGHT ODOMETER
ADDRESS
INSURANCE COMPANY NAME
ADDRESS
BROKER/AGENT NAME
ADDRESS
BINDER OR POLICY NUMBER BEGINNING DATE (mm-dd-yyyy) EXPIRATION DATE (mm-dd-yyyy)
INSURANCE COVERAGE
A. P/A/P
PERSONAL INJURY PER
PERSON
PERSONAL INJURY PER
ACCIDENT
PERSONAL DAMAGE PER
ACCIDENT
B. Combined Single Limit -
OR
(PERSONAL INJURY AND PROPERTY
DAMAGE PER ACCIDENT)
THE UNDERSIGNED CERTIFIES THAT, IN ACCORDANCE WITH THE PROVISIONS OF TITLE 18 U.S. CODE,
SECTION 1001, PROHIBITING THE MAKING OF FALSE STATEMENTS IN CONNECTION WITH ANY FEDERAL
MATTER, THE INFORMATION STATED HERE IS TRUE AND CORRECT. THE REQUIRED INSURANCE
SPECIAL NOTE: FAILURE TO MAINTAIN AN INSURANCE POLICY FOR THIS
VEHICLE WILL RESULT IN CANCELLATION OF REGISRATION AND RECALL
OF THE OFFICIAL FEDERAL LICENSE PLATES.
(EMBASSY SEAL)
AUTHORIZED SIGNATURE(S) DATE(S) (mm-dd-yyyy)
LICENSE
TAG
#:
(FEE):
(C):
(D):
(2#):
I.D.
NUMBER
O:
PD:
PU:
A:
(LEIN)
LH:
T#:
D:
LR:
INSURANCE
C:
P/A/P
COMB
SPLIT
B:
E:
R:
(Q):
E:
I:
F:
* The response time is an estimated average including the time needed to look for, get, and provide the
information required. You do not have to provide the information requested if the OMB approved has expired.
We would appreciate any comments on the estimated response burdens, and recommendations for reducing
them. Please send your comments to A/RPS/DIR, U.S. Department of State, Washington, DC 20520.
DS-100
03-2003
Page 1 of 2
(Formerly DSP-100)
