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Home: ( ) _______________
Office: ( ) _______________
Title Number Registration Plate Number Expiration Date Make of Vehicle Year
Last Name (or Full Business Name) First Name Middle Name PA DL/Photo ID# Date of Birth Telephone
or Bus. ID#
Street Address - Must list a street address. P.O Box # alone is not acceptable.
City
State
Zip Code
I certify that the individual named in Section A is a member in good standing of the organization listed in Section B.
MV-904SP (7-19)
www.dmv.pa.gov
APPLICATION FOR SPECIAL
ORGANIZATION REGISTRATION PLATE
For Department Use Only
Bureau of Motor Vehicles • PO Box 68266 • Harrisburg, PA 17106-8266
PLEASE ALLOW 4-6 WEEKS FOR DELIVERY
Applicant’s Signature in Ink
Date
Name of Organization, Chapter, Post, Lodge, Employer, etc.
Street Address
City
State
Zip Code
Name of Organization Official
Title Signature
I certify that all information given on this application is TRUE and CORRECT and that when I cease to be a member of the above named organization, I
will immediately return the registration plate to PennDOT.
Personalized special organization standard registration plates may contain up to FIVE letters or numbers in combination. If a hyphen or space is used
as part of the registration configuration, it counts as one of the available spaces for personalization. ONLY one hyphen or space is permitted, but not
both. No other special characters are available. Please use capital letters and print clearly. Additional instructions and fees are listed on the reverse
side of this application. NOTE: The shaded boxes contain a pre-printed letter configuration that is specific to this registration plate and cannot be
changed. These letters will appear on your personalized registration plate.
NOTE: In conjunction with replacement of your registration plate, you will receive one registration card. If additional registration cards are desired,
the fee is $2 for each card. Number of duplicate registration cards requested @ $2 each: _________.
NAME OF ORGANIZATION:
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE
Personalized special organization motorcycle registration plates may contain up to FOUR letters or numbers in combination. If a hyphen or space is
used as part of the registration configuration, it counts as one of the available spaces for personalization. ONLY one hyphen or space is permitted,
but not both. No other special characters are available. Please use capital letters and print clearly. Additional instructions and fees are listed on the
reverse side of this application. NOTE: The shaded boxes contain a pre-printed letter configuration that is specific to this registration plate and cannot
be changed. These letters will appear on your personalized registration plate.
FIRST CHOICE
SECOND CHOICE
THIRD CHOICE
A VEHICLE DESCRIPTION AND APPLICANT INFORMATION - Complete this section exactly as information appears on current registration card.
B TO BECOMPLETEDBY ORGANIZATION OFFICIAL
C TO BECOMPLETEDBY ORGANIZATION OFFICIAL - See special instructions on reverse.
D OPTIONAL PERSONALIZATION REQUEST - NOTE: Additional $108 fee required.
E APPLICANT SIGNATURE
r Passenger Car, Truck, Motor Home: Tag Type: ___ r Motorcycle: Tag Type: ___
Please check (
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) the type of registration plate requested:
Moravian College (C7)
M
O
M
M
O
O
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GENERAL INFORMATION REGARDING A SPECIAL ORGANIZATION REGISTRATION PLATE
PLEASE ALLOW 4-6 WEEKS FOR DELIVERY.
This application, with Sections A, D (if applicable), and E, completed in full, must be returned to the organization official for
submission to PennDOT. No applications sent directly to PennDOT by the organization member will be processed. The organization
must complete Sections B and C. NOTE: Only applications for Volunteer Fire Fighter and Emergency Medical Services special
organization registration plates may be mailed directly to PennDOT by the customer.
The applicant listed in Section A must be a registered owner of the vehicle as indicated on the vehicle’s registration
credential. If the vehicle is a leased vehicle, Form MV-1L, “Application for Lessee Information,” must be completed and attached.
(NOTE: Form MV-1L is available on our website at www.dmv.pa.gov.)
PennDOT charges an issuance fee of $27. Participating organizations may charge an initial fee above the $27 PennDOT fee. The
organization fee is $__________. Therefore, the total fee due with this application is $__________. Fees must be made payable to
the organization name of ____________________________________________________________________________________.
NOTE: Special organizations with more than 2,000 organization registration plates may charge a renewal fee for authorization of
continued use of the special organization registration plate. This fee is separate from PennDOT's registration renewal fee. The
renewal fee is at the organization's discretion and is not related to PennDOT.
No special organization registration plate will be duplicated. If your registration plate is lost, stolen or defaced you will need to reapply
for a special organization registration plate by completing this application and submitting it with the appropriate fees. Should you need
an immediate replacement registration plate, please complete and submit Form MV-44, “Application for Duplicate Registration Card,
Replacement of Registration Plate or Weight Class Sticker," along with a fee of $11. A standard registration plate will be issued until
the replacement special organization registration plate can be provided. (NOTE: Form MV-44 is available on our website at
www.dmv.pa.gov.)
Requests for special organization registration plates are restricted to passenger vehicles, trucks with a registered gross weight of not
more than 14,000 lbs., trailers, motorcycles and motor homes. NOTE: Motorcycle registration plates are only available if the
organization has an approved motorcycle special organization registration plate.
NO REFUND of the fee will be issued when an applicant cancels a request after the order is placed.
When the applicant ceases to be a member in the organization as listed in Section B, the registration plate must be returned to
PennDOT. Complete Form MV-44 and submit a fee of $11 for the issuance of a regular series registration plate.
Special organization registration plates are issued in number sequence unless requesting personalization in Section D.
To avoid possible problems with citations with your old registration plate, return it to: Bureau of Motor Vehicles, Return Tag Unit, P.O.
Box 68597, Harrisburg, PA 17106-8597 after you have received your special organization registration plate.
If applying for a Fraternal Order of Police registration plate, the PA State Lodge Seal and the PA State Lodge Recording Secretary
signature must be affixed to this application.
IF PERSONALIZING YOUR SPECIAL ORGANIZATION REGISTRATION PLATE
Personalized special organization registration plates may contain up to FIVE letters and numbers in combination. A preprinted letter
configuration will precede your personalized configuration on your registration plate and cannot be changed. NOTE: If the
organization has an approved design for motorcycle registration plates, the personalized motorcycle registration plates may contain
up to FOUR letters and numbers in combination.
If a hyphen or space is used as part of the registration configuration, it counts as one of the available spaces for personalization. Only
one hyphen or space is permitted, but not both. NOTE: No additional special characters are available.
When requesting a numeric character of zero, please list as " " instead of the alpha character of "O".
PennDOT reserves the right to limit or reject requests.
The registration on your vehicle must be current in order for PennDOT to process your request. The fee to personalize your special
organization registration plate is an additional $108. The additional $108 fee covers the cost of your personalized registration
plate order only and will not renew your vehicle's registration. To renew your registration, please include your completed renewal
application, Form MV-105, “Pennsylvania Registration Renewal Application,” or Form MV-140, “Request for Registration,” and a
separate check or money order in the amount of your registration renewal fee. Payment is to be made by check or money order
payable to the Commonwealth of Pennsylvania. PLEASE DO NOT SEND CASH.
To check personalized registration plate availability, visit PennDOT’s Driver and Vehicle Services website, www.dmv.pa.gov, and
select Plate Availability from the list of services under the Online Services heading. Personalized registration plates will not be
reserved until PennDOT receives payment and a completed application, and approves your requested registration plate configuration
[number(s) and/or letter(s)]. Please note that registration plate requests are processed on a first-come, first-served basis. Although a
requested registration plate configuration may show as being available on the website, it is possible that a request for the same
registration plate configuration may have already been submitted by another customer and may not be available when making
application.
Personalized registration plates will be manufactured on the basis of this application. NO REFUND of the fee will be issued when an
applicant cancels a request after the order is placed with the manufacturer.
Allow eight to 10 weeks for delivery of personalized special organization registration plate.
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Visit us at www.dmv.pa.gov or call us at 717-412-5300. TTY callers — please dial 711 to reach us.
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