Fillable FIREFIGHTER, PROFESSIONAL FIREFIGHTER, RESCUE SQUAD LICENSE PLATES (Virginia Department of Motor Vehicles)

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FIREFIGHTER, PROFESSIONAL FIREFIGHTER, RESCUE SQUAD LICENSE PLATES (Virginia Department of Motor Vehicles)

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VSA 124 (07/01/2020)
Plate Applied For (check one)
(2) PLATE INFORMATION
Rescue Squad (RS)
Professional Firefighter (PF) - (Must show IAF card)
Firefighter (FD) - (Volunteer or Professional)
If original registration, complete sections 1
through 4, section 5 if applicable, sections 6, 7, 9
and 10.
International Association of Firefighters (IAF) ONLY.
Complete sections 1 through 4, section 5 if applicable,
sections 6 and sections 8 through 10. NON-IAF
members are not eligible for this plate.
If original registration, complete sections 1
through 4, section 5 if applicable, sections 6, 7, 9
and 10.
SECTION 2
(6) VEHICLE INFORMATION
TITLE NUMBER VEHICLE IDENTIFICATION NUMBER (VIN) CURRENT PLATE NUMBER EXPIRATION DATE (mm/dd/yyyy)
YEAR MAKE MODEL BODY TYPE AXLES FUEL
EMPTY WEIGHT GROSS WEIGHT
GROSS VEHICLE
WEIGHT RATING
GROSS COMBINATION
WEIGHT RATING
VEHICLE
COLOR
PRIMARY
SECONDARY
SECTION 6
LESSEE'S RESIDENCE/BUSINESS ADDRESS
CITY
ZIP CODESTATE
LESSEE'S FULL LEGAL NAME (last, first, mi, suffix) DMV CUSTOMER NUMBER / FEIN / SSNTELEPHONE NUMBER
(5) LEASE INFORMATION (if applicable)
SECTION 5
IF NEW LOCATION
ENTER DATE
CHANGED
Are any of the owners/lessees on active
military duty or service?
YES NO
LOCATION WHERE VEHICLE IS PRINCIPALLY GARAGED
TOWN OFCITY COUNTY
REGISTRATION MAILING ADDRESS - OPTIONAL
CITY
ZIP CODESTATE
IF YOU WOULD LIKE YOUR REGISTRATION RENEWALS SENT TO AN ADDRESS OTHER THAN YOUR RESIDENCE/BUSINESS ADDRESS, ENTER IT BELOW.
(4) ADDITIONAL INFORMATION
SECTION 4 SECTION 3
OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable)
CITY
ZIP CODESTATE
ZIP CODESTATECO-OWNER'S RESIDENCE/HOME/BUSINESS ADDRESS (Apt # if applicable)
CITY
NOTE: Owners (and Lessees if applicable) MUST provide their residence/home/business address where requested, this
address can not be a P.O. Box. You must complete form ISD-01 if you would like your address(es) updated.
RESIDENCE/BUSINESS JURISDICTION
DMV CUSTOMER NUMBER / FEIN / SSNCO-OWNER'S FULL LEGAL NAME (last, first, mi, suffix) TELEPHONE NUMBER
OWNER'S FULL LEGAL NAME (last, first, mi, suffix) OR BUSINESS NAME (if business owned) DMV CUSTOMER NUMBER / FEIN / SSNTELEPHONE NUMBER
(3) OWNER INFORMATION
(1) REGISTRATION INFORMATION
Registration Type (check one)
Original TransferReissueRenewal
Purpose: Members of fire services and emergency medical services agencies or auxiliaries use this form to apply for vehicle
registration and Firefighter (FD), Professional Firefighter (PF), or Rescue Squad (RS) plates.
Note: You must obtain a Virginia vehicle safety inspection sticker and pay any required local vehicle registration fees to
your city or county. For the city of Virginia Beach only, DMV collects local vehicle registration fees.
Instructions: Mail this completed form with a check or money order (made payable to DMV) to the above address, or present this
completed form to any DMV Customer Service Center (CSC) or DMV Select.
FIREFIGHTER, PROFESSIONAL FIREFIGHTER,
RESCUE SQUAD LICENSE PLATES
VEHICLE REGISTRATION APPLICATION
SECTION 1
( )
( )
( )
VSA 124 (07/01/2020)
Page 2
Any person who, with fraudulent intent, makes a false statement on this application will be guilty of a Class 6 felony (Virginia Code § 46.2-605). I/We
certify:
Failure to comply with Virginia's insurance requirements may result in suspension of your driver's license and vehicle registration.
(9) INSURANCE CERTIFICATION (check only one)
This vehicle is not insured; therefore, I am sending the uninsured motor vehicle (UMV) fee. (This fee provides no insurance coverage).
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 being driven or is inoperable.
SECTION 9
PRIVACY NOTICE
The information, including Social Security Number, is requested in accordance with Virginia Code §46.2-623. Any person who refuses to supply the
required information will be denied a certificate of title and/or registration. Title and registration records may be disseminated in accordance with §§
46.2-208 through 46.2-214, to business, law enforcement or authorized government entities.
PLEASE READ
(10) CERTIFICATION/SIGNATURES
I certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the
information included in all supporting documentation is true and accurate. I 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.
APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
CO-APPLICANT SIGNATURE
SECTION 10
(8) IAF MEMBERSHIP VERIFICATION
You must complete this section if you checked Professional Firefighter plate (PF) above.
Check to indicate presentation of current International Association of Firefighters (IAF) membership card with application. If application is submitted by mail, attach a copy
of the front and back of the IAF card to this application.
SECTION 8
(7) FIREFIGHTER/RESCUE SQUAD PLATE CERTIFICATION
DEPARTMENT/SQUAD CHIEF OR LEADER SIGNATURE
DATE (mm/dd/yyyy)DEPARTMENT/SQUAD CHIEF OR LEADER NAME (print)
EMEGENCY MEDICAL SERVICES/FIREFIGHTER AGENCY, SQUAD OR AUXILIARY
As department/squad chief or leader, I hereby certify that the person named in the Owner Information section of this application is currently a member of a volunteer
emergency medical services agency/auxiliary, volunteer fire department/auxiliary, or is a professional firefighter.
You must complete this section if you checked Firefighter plate (FD) or Rescue Squad plate (RS) above. NOT required for plate renewal or reissue.
SECTION 7
Check here if the person is a professional firefighter
NOTICE TO DMV UPON SEPARATION
Once certified, the department/squad must retain a copy of this application while the person named in the Owner section remains a member. Upon separation of the person
from the department/squad, the department/squad chief or leader must complete this section and send a copy of this signed form to the Department of Motor Vehicles, Special
Registration Unit at the address shown on page 1 within thirty (30) days of the separation date
DEPARTMENT/SQUAD CHIEF OR LEADER NAME (print)
DEPARTMENT/SQUAD CHIEF OR LEADER SIGNATURE
SEPARATION DATE (mm/dd/yyyy)
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FIREFIGHTER, PROFESSIONAL FIREFIGHTER, RESCUE SQUAD LICENSE PLATES (Virginia Department of Motor Vehicles)

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Completed 23 April 2021

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