TENNESSEE DEPA
RTMENT OF REVENUE
Emergency License Plate Authorization
PURPOSE: Owner's
or lessee of motor vehicles who are residents of Tennessee may apply for E-plates if they
are considered emergency personnel as described in Tenn. Code Ann. 55-4-223. This form is not required for
IAFF or FOP plates or for a renewal.
INSTRUCTIONS: Complete this form in it's entirety. This form, along
with the required supporting
documentation, must be submitted to you local county clerk's office. For emergency plate renewals, please
check the name against the current agency listing.
B. PLATE REQUEST AND
PROOF REQUIRED:
RV-F1313901 (6-20)
Plate
E-Plate
Required Documents
Official Identification Card
E-Plate
Civil Air Patrol/Civil Defense Organization/
Emergency Management Agency
Permanent Official Registration Card and letter from local Civil
Defense/Emergency Management Director
E-Plate
Current, Valid Paramedic or EMT license/Emergency Medical
Responder's Certification
E-Plate
Full Time Police Officer
Authorization from the Chief Law Enforcement Officer of the
Organization
E-Plate
Trauma Nurse
Certification from Trauma Center/Emergency Room confirming
applicant is an employed trauma nurse
E-Plate
On Call Surgical Personnel
Licensed or certified according to TCA Title 63 or as a surgical
technologist under Title 68 chapter 57, serving in a hospital,
emergency room/ surgical department confirming employment
Official Identification Card
Statement of Certification from Board of Medical Examiners
and from the Trauma Center in a hospital/other medical facility
Proof of current/former membership in a firefighting unit
Badge as a Member of TN Association of Rescue Squads or list
of members from the Captain of the local Rescue Squad
Approved Denied
A.
APPLICANT
AND VEHICLE INFORMATION:
Full name of
Requestor: _____________________________________________________ Phone: ____________________________
Me
mber or
Retired Firefighter with: _____________________________________________ in __________________________, TN
OR is a Trauma Phyiscian, Nurse,
On Call
Surgical staff at ______________________________ in ___________________, TN
Address: _________________________________________
__ City: __________________________ State: ______
Zip: _____________
Mailing Address (if different): _____________________________________________________________________________________
(name of agency/dept/association)
(name of hospital/medical center)
VIN: _______________________________________________ Make: _____________________________________ Year: __________
C. APPLICANT CERTIFICATION STATEMENT: Under penalties of perjury, I hereby certify this information is
correct to the best of my knowledge.
Signature of Clerk/Designee: ____________________________ Date:___________
This authorization form has been:
Applicant's Signature: _________________________________________________________ Date:_________________________
D. APPROVAL:
Emergency Medical Technician/Paramedic/
Other Emergency
Medical Responders
Firefighters Plate
Rescue Squad
E-Plate
Trauma Physician
Constable
Trauma Physician
Firefighter (including retired)
Rescue Squad
Title
Auxiliary Police Unit w/Civil Defense
click to sign
signature
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signature
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