Georgia Department of Revenue
Motor Vehicle Division
Application for a Special Interest License Plate
Submit this application to your county tag office with the $25 manufacturing fee per license plate. A separate application is
required for each
license plate.
This application must be typed, legibly printed by hand or electronically completed and printed and signed.
Applicant’s Full Legal Name:
Applicant’s Residence Address Including City, State & Zip Code:
County of Residence:
Daytime Telephone Number Including Area Code:
Applicant’s Driver’s License Number:
Check the box indicating the type of license plate requested:
□ African American History & Tourism in Georgia
□ AIDS Survival Project
□ ALS, a/k/a/ ‘Lou Gehrig’s Disease’, Association of GA
□ Alzheimer’s Association
□ Atlanta Braves Foundation
□ Atlanta Falcons Foundation
□ Automobile Racing Hall Fame
□ Beautification Projects in Cobb County
□ Beautification Projects in Georgia
□ Benevolent & Protective Order of Elks
□ BlazeSports Georgia (U.S. Disabled Athletes Fund)
□ Bobwhite Quail
□ Brain-Related Disorders
□ Breast Cancer Awareness
□ Bronze Star
□ Child Abuse Prevention
□ Children’s Healthcare of Atlanta
□ Choose Life
□ Civil War Battlefields & Historic Site Commemorative
□ Dog & Cat Sterilization
□ Dog & Cat Sterilization, Labrador Retriever – ‘Buddy’
□ Family Member Serving in the Military
□ Garden Club of Georgia, The
□ Georgia Center for the Book
□ Georgia Equine Industry
□ Georgia Junior Golf Foundation
□ Georgia War Veterans Nursing Home
□ Global War on Terrorism & Enduring Freedom
□ Global War on Terrorism & Iraqi Freedom
□ Historic Preservation Efforts in Georgia
□ Honor Bronze Star Recipients
□ Honor Educators
□
Honoring All Veterans
□ Honoring Georgia Association of Realtors
□ Honoring Georgia Municipal Clerks
□ ‘In God We Trust’ – Boy Scouts of America
□ Licensed Georgia Physician
□ Maritime History of Georgia’s Coast
□ NASCAR Officially Licensed Registration Plate
□ NASCAR Officially Licensed Registration Plate
for Driver/Car/Team:_______________________
□ National Rifle Association
□ 100 Years of Scouting in the U.S.
□ Pediatric Cancer Research – Joanna McAfee Child
Cancer Foundation
□ Pediatric Cancer Treatment
□ Persons With Diabetes
□ Project Lifesaver
□ Promote Child Care Industry
□ Promoting Arts in Georgia
□ Promoting Bicycle Safety
□ Rotary International
□ School Health & Physical Education Programs
□ Shrine Hospitals for Children
□ Sons of Confederate Veterans
□ Square & Round Dancers
□ Stroke Awareness
□ Support Cobb County Schools
□ Support Georgia Troops
□ Supporting Agriculture in Georgia
□ Supporting Foster Parents
□ Supporting Public Schools
□ Support Our Troops
□ Thanks Mom & Dad
□ Treatment of Autism
□ Trout Unlimited
□ Wildflower
□ Wildlife – Eagle & U.S. Flag
□ Wildlife - Hummingbird
Applicant’s Signature: Date:
Submit this application to your county tag office with the $25 manufacturing fee per license plate. A separate
application is required for each
license plate. An annual special tag fee of $25 may be due at the time of registration,
as well as the usual registration fees and ad valorem taxes.
Please retain your receipt. When the manufacturing requirements have been met (1,000 ‘paid’ requests), you will
need this receipt to register your vehicle with this license plate.
Your license plates will be issued at the time 1,000 ‘paid’ applications are received for the plates you have
requested.
