Dmv 17 A Form – Fill Out and Use This PDF

The DMV 17A form serves as a Special License Plate Application in the State of California, catering to various unique plates that individuals may request for vehicles registered within the state. It allows for the application of original, replacement, and the reassignment, retention, or release of special license plates, highlighting specific requirements based on the type of plate—for instance, Amateur Radio License, Pearl Harbor Survivor, and Purple Heart, among others. For those interested in applying for or managing special license plates, ensure to carefully review the eligibility criteria and required documentation for your specific plate type.

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Dmv 17 A Form PDF Details

Engaging with the comprehensive framework of the DMV 17A form, individuals find a conduit for expressing uniqueness through special license plates in California. This form caters to a range of individuals and vehicles, stipulating specific sections to be completed for different types of applications such as original, replacement, reassignment, retention, or release of special license plates. It meticulously lays out requirements for various distinguished categories including veterans, press photographers, owners of historic vehicles, and recipients of commendations like the Purple Heart or Congressional Medal of Honor, among others. Notably, the form also emphasizes the necessity of adhering to proper documentation and certification processes for application eligibility. The associated costs, although subject to change, are clearly delineated for original issues, duplicates, and reassignments, offering no fee charges for certain valorous recognitions. By mandating signatures under penalty of perjury, it underscores the seriousness and legal obligation of applicants in providing truthful information. This form, thus, serves as a vital link between personal or historical pride and vehicular identification, governed by the thoughtful structuring of regulations by the California Department of Motor Vehicles.

Question	Answer
Form Name	Dmv 17 A Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	dmv form reg 17a, Hawaii, dmv form 17a, 1922

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STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES®

A Public Service Agency

SPECIAL LICENSE PLATE APPLICATION

ORIGINAL

Complete Sections 1, 2, 5

REPLACEMENT

Complete Sections 1, 2, 4, 5

REASSIGN, RETAIN, RELEASE

Complete Sections 1, 3, 5

Special License Plates must be assigned to a vehicle currently registered in California. The department will not honor a change of choice, spacing or a request for refund after the reservation is made.

SECTION 1 — PLATE OWNER (Please print true full name of plate owner or purchaser)

LAST NAME

FIRST NAME

MIDDLE NAME

MAILING ADDRESS (STREET OR P. O. BOX)CITYSTATEZIP CODE

SECTION 2 — TYPE OF PLATE ORDER:

Will be assigned to:	Auto	Truck	Trailer	Motorcycle (Motorcycle plates are available in Amateur Radio License, Purple
Heart, or Antique Motorcycle. Gold Star Family Motorcycle plate is available with decal.)
				LICENSE PLATE NUMBER	VEHICLE IDENTIFICATION NUMBER (VIN)

Plates to be placed on this vehicle, if known:

Documentation Required*		Certiication Required*	Documentation AND Certiication Required*
Amateur Radio License		Pearl Harbor Survivor	Congressional Medal of Honor
	(PROVIDE CALL LETTERS)	Horseless Carriage	Honorary Consul
		Horseless Carriage	Honorary Consul
Legion of Valor		Press Photographer	Historical Vehicle
	(TYPE OF CROSS)
Purple Heart Recipient
Antique Motorcycle
Gold Star Family		*Certify in Sections B, C, or E.	*Attach Copy of Documentation. Certify in Sections A, D,
*Attach Copy of Documentation. See reverse for explanation.		See reverse for explanation.	or E. See reverse for explanation.

A. CONGRESSIONAL MEDAL OF HONOR RECIPIENT CERTIFICATION

I certify that I am a Congressional Medal of Honor recipient. This vehicle is the only vehicle for which the exemption is requested; it will not be used for transportation for hire, compensation, or proit.

SIGNATURE

DATE

B. PEARL HARBOR SURVIVOR CERTIFICATION

The applicant was a member of the United States Armed Forces and stationed at Pearl Harbor, the island of Oahu, or offshore within a distance of three miles, on December 7, 1941, during the hours of 7:55 a.m. to 9:45 a.m., Hawaii time; and received honorable discharge from military service. Signature of an officer of the California Chapter of Pearl Harbor Survivors Association required.

OFFICER’S SIGNATURE

TITLE

DATE

DAYTIME PHONE NUMBER

()

C.PRESS PHOTOGRAPHER CERTIFICATION — MUST BE SIGNED BY EMPLOYER The applicant is regularly employed or engaged as a press photographer or camera person for a:

Newspaper

News Magazine

News Gathering

Newsreel Company

Television Company

EMPLOYER’S SIGNATURE

TITLE

DATE

DAYTIME PHONE NUMBER

()

NAME OF COMPANY

STREET ADDRESS

CITY

STATE

ZIP

D. HONORARY CONSUL CERTIFICATION

I certify that I am a citizen and/or permanent resident of the United States appointed as an honorary consul or similar official by the country listed below for the purpose of facilitating and promoting the interest of that country. I understand that these may be placed only on a vehicle owned or leased by me, and that this application is subject to review and approval by an authorized Department of Motor Vehicles employee.

SIGNATURE

NAME OF FOREIGN COUNTRY REPRESENTED

DATE

E.HISTORICAL VEHICLE AND HORSELESS CARRIAGE CERTIFICATION Historical Vehicle License Plates

I certify that I understand these plates may only be placed on a motor vehicle manufactured after 1922, which is at least 25 years old and is of historic interest. I also certify that I understand that the vehicle for which these plates are issued may be driven in historical exhibitions, parades, or historic club activities only.

SIGNATURE

DATE

Horseless Carriage License Plates

I certify that I understand these plates may only be placed on a motor vehicle manufactured in 1922 or prior, or manufactured with 16 or more cylinders before 1965. I also certify that I understand that the vehicle for which these plates are issued may be driven in historical exhibitions, parades, or historic club activities only.

SIGNATURE

DATE

SUBMIT ORDER AND FEES TO: DMV, SPU – MS D238, P.O. BOX 932345, SACRAMENTO, CA 94232-3450

REG 17A (REV. 7/2011) WWW

SEE REVERSE SIDE

SECTION 3 — REASSIGNMENT (Antique Motorcycle, Historical Vehicle, Horseless Carriage Plates cannot be reassigned or retained)

SPECIAL LICENSE PLATE/DISABLED PERSON LICENSE PLATE NUMBER

WERE REMOVED FROM (VIN)

PLACED ON (CURRENT LICENSE PLATE)

WITH (VIN)

RETAIN INTEREST
Retain for future use (Annual Fee Required for Honorary Consul Corps)	Fee enclosed

RELEASE INTEREST

Release

SECTION 4 — REPLACEMENT ONLY (To replace disabled person license plates, use form REG 156)

I NEED:		PLATE(S) WERE:
One Plate	Two Plates	Lost/Stolen	Mutilated	Surrendered

SECTION 5 — SIGNATURE REQUIRED FOR ALL APPLICANTS

I certify (or declare) under penalty of perjury under the laws of the State of California, that the foregoing is true and correct.

SIGNATURE	DATE	DAYTIME PHONE NUMBER
X		(	)

SPECIAL LICENSE PLATES

Fees subject to change based upon legislative action.

Amateur Radio	Issued to a person licensed by the Federal Communications Commission (FCC). A copy of the valid FCC license must
Station	accompany the application, the plate coniguration is the call letter. Licensee may obtain only one set of plates.
	Fees:	Original $21	Duplicate $18	Reassignment $12

Antique	Issued to a motorcycle manufactured in 1942 or before.A copy of the vehicle registration, manufacturer’s certiicate of origin,
Motorcycle	or other documentation acceptable to the department indicating the manufacture date of the motorcycle must accompany
	the application.
	Fees:	Original $15	Substitute $18

Congressional	Recipient of the Congressional Medal of Honor, receives plates at no additional cost. Certiication on the application must be
Medal of Honor	completed. A copy of the service record, or a copy of the letter which was given to the recipient awarded the Congressional
	Medal of Honor, must accompany the application.
	Fees:	Original None	Duplicate $18	Reassignment None

Gold Star Family	Issued to family members of an active duty member of the Armed Forces killed in the line of duty. Family Members as
	deined in Section 5156 of the Vehicle Code. The Report of Casualty (DD 1300) form from the Department of Defense,
	and the Project: Gold Star License Plate Application (VSD 5-1918) from the California Department of Veterans Affairs must
	accompany the application.
	Fees:	Original None	Substitute $35	Reassignment $15

Historical Vehicle	Issued to a motor vehicle manufactured after 1922, which is at least 25 years old or older and of historic interest. Vehicle
	may only be driven in historical exhibitions, parades, or historic vehicle club activities. For commercial vehicles only: The
	Certiicate of Title must be submitted with the application.
	Fees:	Original $25	Substitute $18

Honorary Consul	Issued to vehicle owned or leased by an honorary consular officer. A photo copy of the Consular Identiication Card issued
Corps	by the US Department of State denoting the applicant’s Honorary Consular status is required.
	Fees:	Original $48	Substitute $38	Reassignment $38	Renewal $38	Retention $38

Horseless	Issued to a motor vehicle manufactured in 1922 or prior, or manufactured with 16 or more cylinders before 1965. Vehicle
Carriage	may only be driven in historical exhibitions, parades, or historic vehicle club activities.
	Fees:	Original $25	Substitute $18

Legion of Valor	Issued to a vehicle, except motorcycle, owned by an Army, Navy, Air Force Medal of Honor, or Army Distinguished Service
	Cross, Navy Cross, or Air Force Cross recipient. A copy of the service record or Department of Defense Form 214 must
	accompany application.
	Fees:	Original None	Substitute $18	Reassignment None	Substitute Decal None

Pearl Harbor	Issued to vehicle, except motorcycle, owned by a member of the US Armed Forces stationed at Pearl Harbor on December
Survivor	7, 1941, with an honorable discharge from military service. Certiication by officer must be completed on the application.
	Fees:	Original None	Substitute $18	Reassignment None

Press	One set of plates issued to a vehicle owned by anyone regularly employed or engaged as a newspaper, newsreel, or
Photographer	television photographer. Certiication by employer must be completed on the application.
	Fees:	Original $21	Reassignment $12

Purple Heart	Issued to vehicle owned by a Purple Heart recipient. Copy of orders, service record, or discharge papers showing Purple
	Heart Award is required with application.
	Fees:	Original None	Substitute $18	Reassignment None

NOTE: All fees and procedures for original and renewal issuance are in addition to regular registration fees pursuant to Vehicle Code Section 4000.

REG 17A (REV. 7/2011) WWW

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1. The dmv form 17a usually requires specific details to be entered. Ensure the subsequent blank fields are finalized:

2. Your next part would be to submit the next few fields: Attach Copy of Documentation See, DAYTIME PHONE NUMBER, TITLE, DATE, Newspaper, News Magazine, News Gathering, Newsreel Company, Television Company, EMPLOYERS SIGNATURE X NAME OF, TITLE, DATE, DAYTIME PHONE NUMBER, STREET ADDRESS, and CITY.

It is possible to make a mistake while filling in the DAYTIME PHONE NUMBER, consequently make sure to look again prior to when you send it in.

3. The following portion is about D HONORARY CONSUL CERTIFICATION I, DATE, REG A REV WWW, SEE REVERSE SIDE, and SUBMIT ORDER AND FEES TO DMV SPU - complete each of these empty form fields.

4. To move forward, your next form section requires filling out a handful of blanks. Examples of these are SECTION REASSIGNMENT Antique, WERE REMOVED FROM VIN, PLACED ON CURRENT LICENSE PLATE, WITH VIN, RETAIN INTEREST, Retain for future use Annual Fee, Fee enclosed, SECTION REPLACEMENT ONLY To, PLATES WERE, RELEASE INTEREST, Release, One Plate, Two Plates, LostStolen, and Mutilated, which you'll find essential to moving forward with this document.

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Dmv 17 A Form – Fill Out and Use This PDF

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