VSA 154 (04-26-2019)
Check one to indicate plate development request type:
NEW special plate license plate REDESIGN of an existing special plate LEGISLATION NOT REQUIRED)
What is the Name of your license plate?
Check to indicate your plate development request CATEGORY for new plates only:
SPECIAL INTEREST - (LEGISLATION REQUIRED) MILITARY - (LEGISLATION REQUIRED) VIRGINIA UNIVERSITY/COLLEGE
OUT OF STATE UNIVERSITY/COLLEGE FRATERNITY/SORORITY LOCALITY
LICENSE PLATE IN DEVELOPMENT
PLATE SPONSOR
PURPOSE: Customers use this form to identify themselves as the sponsor for a new special license plate.
INSTRUCTIONS: Submit this form: EMAIL: PlateDevelopment@dmv.virginia.gov, MAIL: License Plate Development, Room 322 at the
address above or FAX: 804-367-6379.
PLATE REQUEST INFORMATION
WORK TELEPHONE NUMBER
AUTHORIZED REPRESENTATIVE FULL LEGAL NAME (last, first, mi, suffix) STREET ADDRESS (Apt # or P.O. Box if applicable)
CITY
ZIP CODESTATE
HOME TELEPHONE NUMBER CELL PHONE NUMBER FAX NUMBER
SPONSORING ENTITY/ORGANIZATION
CITY
ZIP CODESTATE
EMAIL ADDRESS
SPONSOR CONTACT INFORMATION
The AUTHORIZED REPRESENTATIVE will be the sole contact for all verbal and written communications during the plate development process.
LEGISLATION INFORMATION FOR NEW PLATES (if applicable)
If your plate development CATEGORY is Special Interest OR Military, you must complete this section.
Check to indicate you have complied with the following requirements:
I will provide an accurate monthly count of Preorder Request (VSA 10D) applications collected to the Department of Motor Vehicles,
PlateDevelopment@dmv.virginia.gov, at the end of each month. This information will be shared with the General Assembly and
may be requested more frequently closer to and/or during the General Assembly session.
I have read and understand the following information: (These documents can be found on DMV's website)
• Special Interest Groups and Military Sponsor Information
• License Plate Design Release Agreement
I will contact the DMV License Plate Development office if I have questions and concerns at PlateDevelopment@dmv.virginia.gov.
A Virginia legislator has agreed to sponsor a license plate bill and a License Plate in Development, Acknowledgement of Support (form
VSA 155) has been submitted.
LEGISLATIVE SPONSOR NAME
TELEPHONE NUMBER
CERTIFICATION
CITIZEN SPONSOR/AUTHORIZED REPRESENTATIVE SIGNATURE DATE (mm/dd/yyyy)CITIZEN SPONSOR/AUTHORIZED REPRESENTATIVE NAME
I certify and affirm that all information presented in this section 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.
DMV USE ONLY
YEAR AUTHORIZED BILL NUMBER (if available)
ADDITIONAL INFORMATION
