DSD 9A (09-25-2015)
PERMANENT/TEMPORARY DEALER
PROMOTIONAL PLATES APPLICATION
Purpose: Use this form to apply for permanent/temporary dealer promotional license plates.
Instructions: Mail completed form, with the appropriate fees, to DMV at the address above or submit at any DMV Customer Service Center.
Fees: $100.00 per permanent plate, $25.00 for first temporary plate, $2.00 each additional temporary plate.
DEALER INFORMATION
DEALER NAME DEALER TYPE DEALER NUMVBER
BUSINESS ADDRESS SSN OR EMPLOYER ID #
CITY STATE ZIP CODE
PLATE INFORMATION
INDICATE QUANTITY IN BOXES:
ISSUE PERMANENT PROMOTIONAL PLATE ISSUE GENERIC TEMPORARY PROMOTIONAL PLATE
REQUEST FOR USE OF PLATE ISSUE DEALER DESIGNED TEMPORARY PROMOTIONAL PLATE
EXTENSION OF USE OF PERMANENT PLATE TOTAL QUANTITY OF PLATES ORDERED
NAME OF FIRST EVENT
USE OF PLATES REQUESTED
FROM TO
NAME OF SECOND EVENT
USE OF PLATES REQUESTED
TOFROM
HAVE YOU PREVIOUSLY SUBMITTED CAMERA READY ARTWORK?
NO IF NO, PLEASE ATTACH.YES
NOTE: AUTOMOBILE LIABILITY INSURANCE MUST BE MAINTAINED ON EACH DEALER'S LICENSE PLATE FOR AS LONG AS THAT PLATE REMAINS
VALID.
INSURANCE CERTIFICATION (check one box)
I/we certify that vehicles owned or assigned to my firm are insured by a policy issued through an insurance company licensed to do
business in Virginia and that the policy provides at least the minimum amount of coverage as required by Virginia law.
A certificate of self-insurance number ________________________________ has been issued by DMV pursuant to §46.2-368 for the
series of dealer's license plates issued.
CERTIFICATION
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.
OWNER, PARTNER OR OFFICER NAME (print)
OWNER, PARTNER OR OFFICER SIGNATURE
DATE (mm/dd/yyyy)
DMV USE ONLY
FEE
DECAL NUMBERS ISSUED
FROM TO
