VR-096 (05-17)
Insurance Company Name Policy/Binder #
I/We, the owner(s) of the vehicle described above, apply for a registration for an historic or street rod motor vehicle because:
(check the appropriate box)
Owner’s First Name Middle Last Maryland Driver’s License Number Date of Birth (mm/dd/yyyy)
Owner’s Resident Address City or Town County State Zip Code
Co-Owner’s First Name Middle Last Maryland Driver’s License Number Date of Birth (mm/dd/yyyy)
Description of Vehicle
Year Make Body Style
Title Number
Vehicle Identication Number (VIN)
Please make checks or money orders payable to the MVA. The check must include: (1) Imprinted name and address, (2) Driver’s license number (or
FEIN, if company owned) and (3) Home or work telephone number.
I/We, certify under oath that the vehicle will only be maintained for use in exhibitions, club activities, parades, tours, and similar uses. I/We further
certify that this vehicle will not be used for general daily transportation or any commercial transportation of passengers or property on highways;
and is insured by a Historic Vehicle, Show Vehicle, or Antique Vehicle insurance policy.
Street Rod vehicle 25 calendar years
or older and has been substantially
altered from the manufacturer’s original
design.
Model
Historic passenger vehicle, motorcycle or
truck (with a GVWR of 10,000 pounds or
less); and is 20 calendar years or older; and
has not been substantially altered, remodeled
or remanufactured from its original design.
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Please print all information
Signature of Owner Date Signature of Co-Owner Date
Application for Historic or Street Rod Registration
COMPLETE THIS SECTION FOR HISTORIC OR STREET ROD REGISTRATION
The vehicle must be identiable by a vehicle identication number (VIN) which is a distinct series of numbers assigned by the manufacturer within a
general group of numbers as veried by the manufacturer. Trailers do not qualify for Historic or Street Rod Registration.
Vehicles manufactured at least 50 years before the current model year will be issued one registration plate to be displayed on the rear of the vehicle.
Historic vehicle that is 60 calendar years
or older and has not been substantially
altered, remodeled, or remanufactured
from its original design. THERE IS
A ONE-TIME PERMANENT NON
TRANSFERABLE REGISTRATION FEE.
This registration “does not” qualify for
special registration plates.
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I/We certify under oath that the vehicle will only be maintained for use in exhibitions, club activities, parades, tours, and occasional transportation.
I/We further certify this vehicle will not be used for general daily transportation or primarily for the transportation of passengers or property on
highways, for employment, for transportation to and from employment or school, or for commercial purposes.
Signature of Owner Date Signature of Co-Owner Date
COMPLETE THIS SECTION FOR HISTORIC TRUCKS IN EXCESS OF 10,000 GVWR
TRACTORS, AND MOTORHOMES
PLEASE NOTE SPECIAL RESTRICTIONS ON USE
NOTE: HISTORIC VEHICLES IN THIS CATEGORY MAY NOT BE USED FOR OCCASIONAL TRANSPORTATION. THEY ARE LIMITED TO THE
ACTIVITIES CONTAINED IN THE CERTIFICATION BELOW.
(Check the appropriate box)
Historic Truck over 10,000 GVWR, Tractor or Motor Home that is
60 calendar years or older; and has not been substantially altered,
remodeled or remanufactured from its original design. THERE IS A
ONE-TIME PERMANENT NON TRANSFERABLE REGISTRATION FEE.
This registration “does not” qualify for special registration plates.
The vehicle is a Truck with a GVWR in excess of 10,000 pounds,
Tractor, or Motor Home; and is 25 calendar years or older, and has
not been substantially altered, remodeled or remanufactured from
its original design.
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Vehicles manufactured at least 50 years before the current model year will be issued one registration plate to be displayed on the front of a tractor,
or on the rear of a truck or motor home.
MVA Use Only
Tag Number Issued:
______________________
For more information visit our website at www.mva.maryland.gov or call 410-768-7000.
TTY for the hearing impaired: 1-800-492-4575.
6601 Ritchie Highway, N.E., Glen Burnie, Maryland 21062
