Dmv Form Mv 411 – Fill Out and Use This PDF

New York State Department of Motor Vehicles

EMERGENCYSERVICES CUSTOM PLATES

InNewYorkState,customplatesalloweasyidentificationofvehiclesownedbymembersofemergencyservicesgroups.Theyaresubjecttothefollowing conditions: your current registration must be in the name of the emergency services member (except for Volunteer Ambulance Service and

VolunteerFireFighter-see“note”below);onlyONEsetofplatesmaybeissuedtoanyonecustomer(exceptforWaterRescueTeam).

PLATE SERIES REQUESTED (required proof and initial fees are identified in parentheses):

CivilAir Patrol (PROOF: Valid CivilAir Patrol card – FEE: $60.00)

Emergency Medical Technician (PROOF: Copy of Health Department registration certificate – FEE: $60.00)

Emergency Medical Technician Paramedic (PROOF: Copy of Health Department CertificateAEMT4 – FEE: $60.00)

Ham Radio Operator (PROOF: Copy of FCC License – FEE: $35.00)

NOTE: To obtain custom plates in the two series listed below, the current registration must be in the name of the emergency services member OR his/her spouse.

VolunteerAmbulance Service (PROOF: Letter from ambulance company certifying eligibility. Must be on ambulance company letterhead.

FEE: $43.75)

Volunteer Fire Fighter (PROOF: Letter from Fire Chief certifying eligibility. Must be on fire company letterhead. FEE: $43.75)

Water Rescue Team (PROOF: Copy of an official document that proves you are an active member of a Water Rescue Team –

FEE: $53.75, PERSONALIZED FEE: $85.00).	You may provide up to three choices.Also, you must explain
	the meaning of your chosen combination in the section below.
IMPORTANT: Only the Water Rescue Team plates may be personalized.
Do not complete the personalization section below if you	If the International Symbol ofAccess	is required, only
have chosen a different plate series.	five spaces are allowed.

Choice 1 ___ ___ ___ ___ ___ ___ Choice 2 ___ ___ ___ ___ ___ ___ Choice 3 ___ ___ ___ ___ ___ ___

FILLIN INFORMATION BELOW (Please Print):

Last Name		First			M.I.	Date of Birth (Month/Day/Year)
MailingAddress (Include Street and No.)		Apt. No.	City		State		Zip Code
Signature (Sign Name in Full)				Date		Daytime Phone No. (Area Code)
						(	)
Current Plate Number		Vehicle Model Year		Vehicle Make
Do your current plates have the		If you need the International Symbol ofAccess on your new plates and you do not have it on your current plates,
International Symbol ofAccess?	Yes No	you must also submit a completed form MV-664.1, which may be printed from the DMV website.

CardAccount Number ____________________________________________ Expiration Date ____________________________________

Authorized Signature ➧______________________________________________________________________________________________

Pleasedonotsendcash! MakecheckormoneyorderpayabletoCommissionerofMotorVehicles.Pleaseallow4to6weeksfordelivery.The annualrenewalfeeis:$31.25forCivilAirPatrol,EmergencyMedicalTechnicianandEmergencyMedicalTechnicianParamedic;$25.00 forWater RescueTeam($56.25forWaterRescueTeampersonalizedplates);$15.00forAmbulanceService;and$6.25forHamOperators.Thereisno annualfeeforVolunteerFireFighter.Thesefeesareinadditiontoyourvehicleregistrationrenewalfee.Youwillbebilled fortheplateseverytwo yearswhenyourenewyourregistration.

NOTE: ● Plates are not ordered until we receive ALL required documents and fees.

●The next available number in the series will be assigned. You cannot choose your own standard plate number.

●Falsifying documents will result in cancellation of the custom plates.

●Plates will be mailed to the address on the vehicle’s registration file. If you have moved and not updated your address on your registration record, please complete the Change ofAddress form MV-232.

IMPORTANT: Making a false statement in any registration application, or in any proof or statements in connection with it, or deceiving or substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in the revocation or suspension of the registration and/or the applicant’s license, pursuant to regulations established by the Commissioner. The act of renewing these plates shall constitute your certification that you remain eligible to continue holding these plates.

	If you have any questions, or need additional information, call 518-402-4838 or visit www.nysdmv.com
	Return this completed form, the required proof and your payment to:
MV-411 (4/10)	Department of Motor Vehicles, Custom Plates Unit, PO Box 2775,Albany NY12220.