DSD 4 (05/25/2015)
DEALER APPLICATION
FOR 5-DAY TRANSPORT PLATES
Purpose: Motor Vehicle Dealers use this form to apply to purchase transport plates.
Instructions: Complete form and submit with driver's license and dealership payment, to any DMV customer service center.
MOTOR VEHICLE DEALERS MUST PROVIDE THE PROPER INSURANCE ON ALL 5-DAY TRANSPORT LICENSE PLATES
DEALER INFORMATION
DEALER NUMBER DEALER TRADE NAME
DEALER BUSINESS ADDRESS CITY STATE ZIP CODE
INDIVIDUAL AUTHORIZED TO PICK UP PLATES NAME (print) * DRIVER LICENSE NUMBER
PLATE INFORMATION
PLATE TYPE AND QUANTITY
FOR DMV USE ONLY
5-DAY TRANSPORT REGULAR
(10 pairs of plates per pack)
NUMBER OF PACKS
X $15 per pack
$
FROM PLATE # TO PLATE #
5-DAY TRANSPORT MOTORCYCLES
(10 single plates per pack)
NUMBER OF PACKS
X $15 per pack
$
FROM PLATE # TO PLATE #
TOTAL
$
CERTIFICATION
I/We certify that vehicles owned or assigned to my/our firm are insured by an insurance company licensed to do business in Virginia and that the policy
provides at least the minimum amount of coverage as required by law.
A certificate of self insurance # _______________________________ has been issued by DMV pursuant to §46.2-368 with respect to each dealer's license
plate issued.
I/we 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 understand
that knowingly making a false statement or representation on this form is a criminal violation.
I/we further certify that all 5-day transport plates will be issued by this dealer in full compliance with the Motor Vehicle Dealer Licensing Laws of the Code of
Virginia.
DEALER, DEALER-OPERATOR, OWNER OR PARTNER NAME (print) TITLE DATE (mm/dd/yyyy)
DEALER, DEALER-OPERATOR, OWNER OR PARTNER SIGNATURE
EXECUTED AND SIGNED IN THE
COUNTY CITY OF
DMV USE ONLY
* DRIVER LICENSE NUMBER PRESENTED (for plate pickup) ISSUING STATE
DMV AUTHORIZED SIGNATURE
