Fillable Mail Drop 801Z Special Plates Unit Motor Vehicle

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Mail Drop 801Z Special Plates Unit Motor Vehicle

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SPECIAL PLATE APPLICATION
Mail Drop 801Z
Special Plates Unit
Motor Vehicle Division
PO Box 2100
Phoenix AZ 85001-2100
Plate Design Requested (see list)
Plate Option Requested (check one)
Standard Standard Disability Personalized Personalized Disability
Plate Size
Full Small
Owner/Lessee Name (first, middle, last, suffix)
Vehicle Year
Make
Mailing Address ( Check here if your address has changed. )
City
State
Zip
Current Plate
Registration Expires
All Plates – The annual renewal special plate fee will be due when your vehicle registration is next renewed. If your registration
expires within the next three months, you may wish to renew the registration early, before submitting this application, to avoid
the first annual renewal special plate fee.
Plates may only be issued for a vehicle that is currently registered or leased in your name. If leased but not registered in your
name, submit a document showing you as lessee. Some plates may not be issued to commercial vehicles with a declared gross
vehicle weight of 26,001 lbs or more. A lost or mutilated plate may be replaced for $5.00 (plus postage/handling, if mailed).
Please be aware that it is a Class 2 misdemeanor to alter or modify any Arizona license plate, per A.R.S. §28-2531(B)(1).
Disability Symbol
(International Symbol of Access) – For parking in specially marked spaces. Must complete form # 96-0104
(available online), signed by a physician, hospital administrator or registered nurse practitioner; or have one on file. Available to
individuals and organizations.
Personalized Plates – Allow six weeks for processing. Your new plate will be mailed to you. All personalized choices must be
approved. We may refuse to issue or may suspend any plate that suggests a meaning that is offensive, misleading or that
duplicates any existing plate or plate series. The fee for a remake of a plate already ordered or issued is $5.00 plus
postage/handling; if the vehicle registration has expired, full renewal fees are required.
If after one year from the vehicle registration refund or expiration, you have not transferred the plate to another vehicle you
own, the plate format will be canceled and become available for reissue to another person.
All personalized plates (except for trailers) may have the disability symbol as the first character, at no added charge. If you are
eligible, check the
in first column below, instead of filling in a letter/number in that box (see example), and attach form #
96-0104. The number of characters available for a letter/number for that plate will be reduced by one to allow for the symbol.
• Use only capital letters and numbers. No punctuation or other symbols. Use I for i, L for l, 1 for one, and V (underlined) for v.
• Choices with the maximum number of characters may not have spaces. Choices will automatically be centered on the plate.
• Choices with less than the maximum characters may have half spaces (indicate with single slash “/” ) or full spaces.
• To check on the availability of your choice, visit www.servicearizona.com.
Each single slash / = half space
Blank = full space
Disability symbol replaces 1st character
C
M Y C A R
B
E S A F E
B S A F E
Print Clearly! Explain the meaning/message of each of your choices in detail.
1st Choice
Meaning/Message (required)
2nd Choice
Meaning/Message (required)
3rd Choice
Meaning/Message (required)
I certify that I read and comply with all of the requirements on this form for the special plate indicated above. If you are not an
owner or lessee, but are buying the plate as a gift, the plate will be mailed to the owner or lessee of the vehicle.
Applicant Signature
Daytime Phone
( )
Date
Maximum number of characters for each personalized plate is indicated in parentheses. Fees for Initial Application Fee/Annual Renewal Fee are
Standard $25/25, Personalized $50/50, unless otherwise noted. Add postage/handling for plates that are mailed; add $4.89 for one full size
plate (6” x 12”), $4.89 for two plates, $4.64 for small size plate (4” x 7”). For additional information visit www.azdot.gov or call:
Phoenix 602-255-0072, Tucson 520-629-9808, elsewhere in Arizona 800-251-5866, (Hearing/Speech Impaired–TDD systems only:
Phoenix 602-712-3222, elsewhere 800-324-5425)
MVD Use
Entry Date
Order Date
Special Instructions/Plate Number Issued
Receipt Number
Amount Paid
•
Please read all the requirements on this form
•
Make check payable to: Motor Vehicle Division
•
Most plates may be ordered online at www.servicearizona.com.
/
/
96-0143 R05/18
azdot.gov
Save time, skip this form and order online!
Order Online
*Note: Disability plate requests are not available online, paper form required (see below).
AZ HISTORICAL SOCIETY
N/A
Plates Available as Personalized or Standard
Regular Personalized Full size plate (7 characters maximum), Small size plate
1
(5).
Alternative Fuel (7) Standard $8/0, Personalized $33/25 Must be powered by liquefied petroleum gas (LPG, propane), natural gas (CNG/LNG), a
blend of 70% alternative fuel and 30% petroleum-based fuel, hydrogen, solar or electric (excluding golf carts).
Amateur Radio (6) Available personalized only (with call sign) $25/25 Proof of current amateur radio license from Federal Communications
Commission. $17 of the fee goes to a special fund for college scholarships, youth programs, and emergency response communications.
Arizona Agriculture (7) No requirements. Available to everyone. $17 of the fee goes to the Arizona FFA which provides premier leadership,
personal growth and career success opportunities for students enrolled in Agricultural Education programs in Arizona.
Arizona Cardinals (6) No requirements. Available to everyone. $17 of the fee goes to support programs designed to improve the lives of children,
women and minorities in AZ.
Arizona Centennial (6) No requirements. Available to everyone. $17 of the fee goes to the Arizona geological survey to pay costs related to the
maintenance and operation of mining, mineral and natural resources educational museum.
Arizona Coyotes (6) No requirements. Available to everyone. $17 of the fee goes to the Arizona Coyotes Foundation, which supports non-profit
organizations that serve children and service men and women with healthcare, education, cultural arts and youth sports in the State of Arizona.
Arizona Diamondbacks (6) No requirements. Available to everyone. $17 of the fee for youth education/development, and housing and healthcare for
low-income persons.
Arizona Highways (7) No requirements. Available to everyone. $17 of the fee goes to the Arizona Highways magazine.
Arizona Historical Society (5) No requirements. Available to everyone. $17 of the fee goes to museums and programs state-wide.
Arizona Science Center (7) No requirements. Available to everyone. $17 of the fee goes to delivering science education to students, teachers and
families.
Arizona Sportsmen for Wildlife Conservation (7) No requirements. Available to everyone. $17 of the fee goes to fund wildlife habitat projects,
outdoor recreational and educational opportunities.
Arizona State University (6) Two plates issued. No requirements. Available to everyone. $17 of the fee for academic scholarships.
Barrett-Jackson (6) No requirements. Available to everyone. $17 of the fee goes to Barrett-Jackson Charities, to benefit the 2018 “Driven Hearts”
initiative for the American Heart Association.
Boy Scouts of Arizona (6) No requirements. Available to everyone. $17 of the fee goes to the Grand Canyon Council of Boy Scouts of America.
Channel 8 PBS (7) No requirements. Available to everyone. Arizona Foundation of Public Broadcast Television, which provides noncommercial and
nonsectarian educational television services.
Character Education (6) No requirements. Available to everyone. $17 of the fee for character education programs.
Child Abuse Prevention (7) No requirements. Available to everyone. $17 of the fee for child abuse prevention.
Childhood Cancer Research (7) No requirements. Available to everyone. $17 of the fee for childhood cancer and rare childhood disease research.
Classic Car (3) Vehicle must be on the list of classic cars filed with the Motor Vehicle Division by the Classic Car Club of America. This list is
updated every five years. May require a vehicle inspection.
Environmental (7) Two plates issued. No requirements. Available to everyone. $17 of the fee for environmental education.
Extraordinary Educators (6) No requirements. Available to everyone. $17 of the fee for Arizona public educators who propose extraordinary
activities, projects or lessons for students in K-8.
Families of Fallen Police Officers (7) No requirements. Available to everyone. $17 of the fee goes to help in the healing of family survivors of police
officers who died in the line of duty in Arizona.
Fire Fighter (6) Applicant must submit an original certification form provided by the Professional Fire Fighters of Arizona
. $17 of the fee goes to the
organization.
Firefighter Safety Training (6) No requirements. Available to everyone. $17 of the fee is used to provide scholarships for life safety training of
firefighters in Arizona.
First Responder Available full size or small size plate
1
. Personalized full size (7), small (5). No requirements. Available to everyone. $17 of the fee
goes to programs that provide assistance to Public Safety state-wide.
Girls Scouts (6) No requirements. Available to everyone. $17 of the fee goes to the Girl Scouts for enriching experiences, such as extraordinary field
trips, sports skill-building clinics, community service projects, cultural exchanges and environmental stewardships.
Gold Star Family (5) Must be spouse or (by adoption or blood) a child, parent, brother or sister of a person who lost his/her life while on active duty
in the U.S. Armed Forces. $17 of the fee for construction and maintenance of the Enduring Freedom Memorial.
Golden Rule (7) No requirements. Available to everyone. $17 of the fee for programs that demonstrate the promotion of the golden rule in schools
and communities in AZ.
Grand Canyon University (6) No requirements. Available to everyone. $17 of the fee goes to the university for academic scholarships.
Hunger Relief (7) No requirements. Available to everyone. $17 of the fee goes to Hunger Relief Special Plate Fund, which will be used to fund
organizations that provide food distribution to hungry people in Arizona.
In God We Trust (6) No requirements. Available to everyone. $17 of the fee goes to promote the national motto “In God We Trust”.
Keep Arizona Beautiful (6) No requirements. Available to everyone. $17 of the fee for the litter prevention and litter cleanup special plate fund.
Luke Air Force Base Available full size or small size plate
1
. Personalized full size (5), small (4). No requirements. Available to everyone. $17 of the
fee goes to support the Men, Women, Families and Mission of Luke AFB for programs and services geared towards Morale & Well-Being,
Culture & Tradition and Mission Sustainability.
Masonic Fraternity (7) No requirements. Available to everyone. $17 of the fee goes to charities supported by the Arizona Masons.
Midwestern University (6) No requirements. Available to everyone. $17 of the fee goes to support Health Sciences Academic Scholarships.
Military Support/Freedom Available full size or small size plate
1
. Personalized full size (7), small (5). No requirements. Available to everyone. $17
of the fee goes to benefit veterans in Arizona.
Navajo Nation (6) No requirements. Available to everyone. $17 of the fee goes to the tribe for traffic control devices.
Northern Arizona University (6) Two plates issued. No requirements. Available to everyone. $17 of the fee for academic scholarships.
Pet Friendly/Spay & Neuter (6) No requirements. Available to everyone. $17 for animal spaying/neutering.
Phoenix International Raceway (6) No requirements. Available to everyone. $17 to Motorsports Charities to provide resources and charitable
support for children through education, medical treatment, dream experiences and volunteerism.
Phoenix Suns (6) No requirements. Available to everyone. $17 for youth education and development, college scholarships and community
development.
Pink Ribbon/Cancer Awareness (6) No requirements. Available to everyone. $17 for breast and cervical cancer screening and diagnostic awareness
and outreach services in Arizona.
Purple Heart Available full size or small size plate
1
. Standard $25/5, Personalized full size (6), small (4) $50/30. Must be a veteran and a Purple
Heart recipient and provide a copy of a DD214 or 215, WDAGO forms 53-55 or 53-98, NAVPERS 553 or NAVMC 78 that indicates Purple
Heart recipient, or provide an original letter from the Arizona Dept. of Veterans’ Svcs verifying eligibility. Initial application fee goes to benefit
Veterans in Arizona.
2, 3
Route 66 Available full size or small size plate
1
. Personalized full size (6), small (4). No requirements. Available to everyone. $17 to the preservation
of the historical federal highway.
San Carlos Apache Tribe (6) No requirements. Available to everyone. $17 to the tribe for traffic control devices.
Southwest PGA Available to everyone. $17 goes to support golf scholarships for youth based on community involvement and academic excellence.
Initial Application Fee $25 / Annual Renewal Fee $25.
Special Olympics Arizona (6) No requirements. Available to everyone. $17 goes to support inclusion of individuals with/without disabilities through
sports, health, youth and adult leadership and other self-advocacy programs.
Street Rod (7) Available personalized only $25/25. Must retain the basic original body style as manufactured in 1948 or before.
Thunderbird School of Global Management (6) No requirements. Available to everyone. $17 for the school’s operations and activities.
Transplantation Awareness – Organ Donor (6) No requirements. Available to everyone. $17 for organ transplantation awareness programs.
University of Arizona (6) Two plates issued. No requirements. Available to everyone. $17 for academic scholarships.
U.S. Marine Corps - Available full size or small size plate
1
. Personalized full size (6), small (4). No requirements. Available to everyone $17 of the
fee is used to award scholarships to children of Marines and Navy Corpsmen who were killed or wounded in combat or who have demonstrated
financial need.
Veteran Two plates issued. Available full size or small size plate
1
. Standard $25/25; Personalized full (6), small (4) $50/25. Copy of DD214, 215, 2
(retired), 2 (reserve), 1173 or 256A, an original statement of honorable service from U.S. Dept. of Veterans Affairs or Arizona Dept. of Veterans’
Svcs, or any of these cards: American Legion, Arizona credential with Veteran distinguishing mark, Department of Veterans Affairs veteran
identification, Disabled American Veterans, Military Officers Association of America, Military Order of the Purple Heart, Veterans of Foreign
Wars, Vietnam Veterans of America or U.S. military ID (active or inactive duty)
3
. $17 of the initial and annual renewal fee goes to a special fund
to benefit Veterans in Arizona.
White Mountain Apache Tribe (6) No requirements. Available to everyone. $17 to the tribe for traffic control devices.
Women Veterans (6) No requirements. Available to everyone. $17 to Arizona Veterans’ Donation Fund.
Plates Available as Standard Only (No Personalized Plate Available)
Congressional Medal of Honor No fee. Two plates issued. Must be recipient of Congressional Medal of Honor and provide an original letter
verifying eligibility from the Arizona Dept. of Veterans’ Svcs.
2
Former Prisoner of War $15/5 Two plates issued. Must have received an honorable discharge and provide a copy of a current membership card
from the American Ex-Prisoners of War association, or an original letter from the Arizona Dept. of Veterans’ Svcs verifying eligibility. The initial
application fee goes to benefit Veterans in Arizona.
2, 3
Historic Vehicle $25/10 (add postage/handling $8.39 full size or $4.89 small size plate) Vehicle must bear a model date of original manufacture that
is at least 25 years old. May require a vehicle inspection.
Pearl Harbor Survivor $25/5 Two plates issued. Must have been active duty on station during the attack, received an honorable discharge and
provide form AVSC 02-25, Part II from the Arizona Dept. of Veterans’ Svcs. The initial application fee goes to benefit Veterans in Arizona.
2, 3
1
Small size plate is limited to motorcycles and golf carts, except that trailers with a Regular plate can have either small or full size.
2
May transfer plate to another vehicle. No transfer fee.
3
May also be issued to the spouse, parent, child, brother or sister of an eligible person who has been issued this plate.
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Mail Drop 801Z Special Plates Unit Motor Vehicle

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Completed 12 August 2020

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