VSA 14 (07/01/2019) -- Page 2
DAYTIME TELEPHONE NUMBER
( )
DAYTIME TELEPHONE NUMBER
( )
CO-APPLICANT SIGNATURE
DATE (mm/dd/yyyy)
APPLICANT/AUTHORIZED CORPORATION/COMPANY REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
I/We certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information
included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand that knowingly
making a false statement or representation on this form is a criminal violation.
If the vehicle to be registered has a gross weight of 26,001 pounds or more, I/we further certify and affirm my/our knowledge of all applicable state and federal motor carrier
safety and hazardous materials laws and regulations.
If I/we have requested Amateur Radio Operator Call Letter license plates, I/we certify and affirm that I/we will return those plates to DMV for another type of license plate
within 90 days if my/our amateur radio license becomes invalid for any reason.
An authorized representative must sign for a corporation or company.
CERTIFICATION
New Plates: (check one)
Reissue Plates:
(check one)
Lost Mutilated/Destroyed Illegible Confiscated I want a new plate design/character combination
Small size plate (trailer gross weight must be 4,000 lbs or less) Regular size plate Trailer Permanent - one-time fee (check one):
For Hire Plate (enter description):
(examples: Taxi, Passenger For Hire, Tow Truck, etc.)
PERSONALIZED LICENSE PLATES: To request personalized license plates, check this box and enter your choices below.
1
st 2nd
3rd 4th
Farm Plate - You must ALSO complete the Farm Vehicle Plate Certification (VSA 131).
may be issued to trailers, travel trailers, or semi-trailers; trucks/tractor trucks with a GVWR or GCWR of more than 26,000 lbs.; trucks/tractor trucks with
GVWR or GCWR of 7,501 to 26,000 lbs. if used for business only; farm vehicles registered pursuant to § 46.2-698; taxicabs or other motor vehicles
performing a taxicab service; common carrier vehicles
Special Plate (enter type below)
Great SealHeritage (Dogwood-Cardinal)
Standard - (Virginia is for Lovers) Autumn
Patriot
Mountain to Seashore
Permanent Plate -
Note: Virginia offers more than 200 unique plates for our citizens. Please visit www.dmvNow.com
for a listing of special plates available.
Not all plates are available for all vehicle types and some special plates require a certification form. Review our website for additional information.
PLATE INFORMATION
DMV USE ONLY
CSR STAMP
LICENSE PLATE NUMBER
CSC TRANSACTION FEE (TOTAL RENEWALS X $5)
CHECK IF NO FEE □
DECAL MONTH DECAL YEAR ADDITIONAL FEE
REGISTRATION FEE REISSUE FEE UMV FEE FEE TOTAL
Check to indicate how the vehicle being registered will be used. (check all that apply)
Do you hold a valid intrastate operating authority certificate/permit?
If no, and you are a passenger carrier you must also complete the For-Hire Vehicles Registration Request (MCS115).
Common Carrier - Regular Route Employee Hauler Sight-seeing Carrier Property Carrier *
Common Carrier - Irregular Route Contract Passenger Carrier Non-Emergency Medical Transport Household Goods Carrier *
Nonprofit/Tax-Exempt Taxicab Exempt Operations - Passengers * Exempt Operations - Property *
* You must also complete the For-Hire Vehicles Registration Request (MCS115)
PROPERTY CARRIER OPERATIONSPASSENGER CARRIER OPERATIONS
YES NO
FOR HIRE INFORMATION
POWER OF ATTORNEY FOR NON-RESIDENT(S) AND CORPORATION(S) NOT DOMICILED IN VIRGINIA: Pursuant to the provisions of Virginia Code §46.2-601, I/we
appoint the Commissioner of the Department of Motor Vehicles of the Commonwealth of Virginia, to be my/our true and legal agent upon whom all legal processes against
me/us may be served in any legal proceeding arising from the operation and/or use of any motor vehicle registered in my/our name(s) in the Commonwealth of Virginia. I/we
agree that any lawful process or notice to me/us which is served on the Commissioner shall have the same legal effect as if served on me/us within the Commonwealth of
Virginia.
PRIVACY NOTICE: The information, including Social Security Number, is requested in accordance with Virginia Code §§46.2-623 and 46.2-629. Any person who refuses
to supply the required information will be denied a certificate of title and/or registration. By signing this form, you authorize DMV’s exchange of title and registration records
with business, law enforcement, or government entities and you authorize DMV’s exchange of title and registration records in accordance with Va. Code §§46.2-208 through
46.2-214 and 18 U.S.C. 2721.
NOTICE
INSURANCE CERTIFICATION
I/We certify that (check one):
This vehicle is insured by a liability policy issued through an insurance company licensed to do business in Virginia and it will
remain insured while registered, whether or not it is operated. Penalties are severe for violation of this requirement. Be advised
that the amount of liability coverage required is higher for vehicles that are operated for hire.
NAME OF INSURANCE COMPANY
This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. (This fee provides no insurance coverage.) A vehicle must be insured
with liability coverage when it is registered, and it must remain insured while registered, whether or not it is operated, or the uninsured motor vehicle fee must be paid.
Penalties are severe for violation of this requirement.
