Section C - To be completed by applicants for transportation to a Maryland State inspection station
Means by which to transport my vehicle to an authorized Maryland inspection station are unavailable. I understand that one 30 day temporary registration
will be issued for the purpose of transporting the vehicle to and from an inspection station or weigh station or both.
Section B - To be completed by Maryland members of the U.S. Armed Forces assigned out of state
Section A - To be completed by all applicants regardless of reason for waiver
Year Make Model Vehicle Identification Number
Full Name of Vehicle Owner Full Name of Vehicle Co-Owner
Owner’s Street Address
Certification of Insurance:
The vehicle described above is covered by personal injury and property damage insurance in the minimum
amounts required by the laws of Maryland.
Odometer Mileage upon Transfer of Ownership
(required by federal/state regulations):
Odometer reading is ___________________ (no tenths)
❒ 1. The mileage stated is in excess of its mechanical limits.
❒
2. The odometer reading is not the actual mileage. Warning - Odometer Discrepancy
Insurance Company Policy/Binder Number Agent/Broker
Owner’s Signature Date Co-Owner’s Signature Date
I certify that I am a member of the U.S Armed Forces officially assigned to duty at the following military base.
Reason for Waiver Request:
❒
I am a Maryland resident and a member of the U.S Armed Forces stationed outside of Maryland.
(use section B)
I request an inspection waiver due to the above information. Upon returning to Maryland, I will have the vehicle inspected at an authorized
Maryland safety inspection station.
Signature of Serviceman Printed Name Date
The above named serviceman is assigned to official duty at the above named military base.
Signature of Commanding Officer (rank) Printed Name Date
Owner’s Printed Name Co-Owner’s Printed Name
Description of Vehicle:
Military Address
Name/Location of Base
Maryland Tag #
Co-Owner’s Street Address
City County State Zip Code
City County State Zip Code
FEIN #
Reminder: This vehicle must pass a MD safety inspection within 30 days. You must either submit the inspection certificate to the MVA (unless electronically
submitted by the inspection station); or return the license plates. Failure to comply will result in the flagging of the registration and a tag pickup order placed
against the vehicle. TEMPORARY EXPIRATION DATE: ______________________________________
