APPLICATION FOR REGISTRATION (PERSONAL VEHICLE)
OFFICE OF FOREIGN MISSIONS
DIPLOMATIC MOTOR VEHICLE OFFICE
U.S. Department of State
SEE INSTRUCTIONS ON REVERSE
OMB Approval No. 1405-0072
Expires 03-31-2006
*Estimated burden 30 minutes
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)
I.D. NUMBER
PRINCIPAL
DEPENDENT
VEHICLE IDENTIFICATION NUMBER MAKE MODEL
BODY
LIEN HOLDER/LEGAL OWNER (Name in Full) If the registered owner is the legal owner, write NONE.
YEAR WEIGHT ODOMETER
ADDRESS
INSURANCE COMPANY NAME
ADDRESS
BINDER OR POLICY NUMBER
BEGINNING DATE (mm-dd-yyyy)
EXPIRATION DATE (mm-dd-yyyy)
INSURANCE COVERAGE
PERSONAL INJURY/PERSON PERSONAL INJURY/ACCIDENT PERSONAL DAMAGE/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 a federal matter, the information stated here is true and correct. The required
insurance liability coverage will be maintained for all drivers of this vehicle at all times.
SPECIAL NOTE: Failure to maintain an insurance on this vehicle at the required liability
limits of $100,000 per person/$300,000 per accident/$100,000 property damage or
$300,000 combined single limit for this vehicle will result in cancellation of registration
and recall of the official federal license plates.
(EMBASSY SEAL)
OWNER'S SIGNATURE DATE (mm-dd-yyyy)
1. LICENSE PLATE NUMBER
ATTENTION: Application cannot be processed without completion of gray shaded areas.
Type all answers or write in block letter.
In addition to this form, you must sibmit (a) the Certificate of origin or the Vehicle Title and
(b) a photocopy of the insurance binder sheet or declaration page as proof of liability coverage.
1.
2.
OWNER NAME (Surname, First, MI - as given to Office of Protocol)
DATE OF BIRTH (mm-dd-yyyy) VISA
I.D. NUMBER
PRINCIPAL
DEPENDENT
CO-OWNER NAME (Surname, First, MI - as given to Office of Protocol
DATE OF BIRTH (mm-dd-yyyy) VISA
COLOR
COMBINED SINGLE LIMIT
CO-OWNER'S SIGNATURE DATE (mm-dd-yyyy)
DS-101
03-2003
CHECK #
FEE
2. LICENSE PLATE #
3. LICENSE PLATE #
4. LICENSE PLATE #
5. LICENSE PLATE #
I.D. NUMBER (Check)
O:
C/O:
A:
INSURANCE CARRIER:
INSURANCE BROKER:
INSURANCE LIMITS:
BROKER/AGENT NAME & ADDRESS
* 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.
Page 1 of 2
(Formerly DSP-101)
