DSD 27 A (08/25/2015)
ASSIGNED OPERATOR INFORMATION
FULL LEGAL NAME (last) (first) (middle) (suffix)
STREET ADDRESS CITY STATE ZIP CODE
TELEPHONE NUMBER FAX NUMBER EMAIL ADDRESS
VEHICLE INFORMATION
VEHICLE IDENTIFICATION NUMBER (VIN) VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL
PLATE INFORMATION
DATE ISSUED (mm/dd/yyyy)
TIME ISSUED
PMAM
DATE EXPIRES (mm/dd/yyyy) VEHICLE MILEAGE AT ISSUANCE
TIME EXPIRES
PMAM
DEALER PLATE
DEALER PLATE NUMBER
TRANSPORT PLATE
TRANSPORT PLATE NUMBER
DEALER CERTIFICATION
In accordance with Virginia Law, the above referenced plate is approved/authorized to be used for 3 days or 750 miles (whichever occurs first) Note: Dealer License Plates or Transport
Plates may not be used on the same truck or tractor truck by the same prospective purchaser for a period of 60 days.
I further 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.
DEALERSHIP NAME (print) DEALER CERTIFICATE NUMBER
PERMISSION FOR USE OF DEALER OR TRANSPORT
PLATE ON TRUCKS OR TRACTOR TRUCKS
Purpose: Motor vehicle dealers use this form to allow bona fide prospective purchasers or their authorized agent to use a dealer or transport
plate on trucks or tractor trucks - that may be laden - for a period of 3 days or 750 miles, whichever occurs first.
Instructions: See Instructions on reverse for details.
Instructions (back of form)
1. Dealer completes form and makes a copy.
2. Dealer issues original form to assigned operator. Original form must be in the immediate possession of the person operating
or authorized to operate the truck or tractor truck.
3. The dealer retains the copy for 5 years. Dealer retained copies are subject to inspection by law enforcement and authorized
representatives of the Department of Motor Vehicles or the Motor Vehicle Dealer Board.
DEALERSHIP REPRESENTATIVE NAME (print)
DEALERSHIP REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
