Mv 904So Form – Fill Out and Use This PDF

MV-904SO(1-15)

www.dmv.state.pa.us

Check One: Leased Vehicle: qYES qNO

NOTE: If the vehicle is a leased vehicle, Form MV-1L, “Application for Lessee Information,” must be completed and attached. Form MV-1Lis available on our website at www.dmv.state.pa.us.

AVEHICLE DESCRIPTIONANDAPPLICANT INFORMATION (Completethissectionexactlyasinformationappearsoncurrentregistrationcard.)

Title Number

Registration Plate Number

expiration Date

Make of Vehicle

Year

Last Name (Or Full Business Name)

First Name

Middle Name

PADL/Photo ID# or

Date of Birth

Bus. ID#

StreetAddress - Must list a street address. P.O. Box # alone is not acceptable.

City

State

Zip Code

Telephone Number

Home (

) ___________________

Work (

) ___________________

NOTE: In conjunction with replacement of your plate, you will receive one registration card. If additional registration cards are desired, the fee is $2 for

each card. Number of Duplicate Registration Cards Requested @ $2 each _________.

B

TO BE COMPLETED BYORGANIZATION OFFICIAL

NAME OF ORGANIZATION

Name of Organization, Chapter, Post, Lodge, employer, etc.

Telephone Number

StreetAddress

City

State

Zip Code

C

TO BE COMPLETED BYORGANIZATION OFFICIAL(Seespecialinstructionsbelow.)

I certify that the individual named in SectionAis a member in good standing of the organization listed in Section B.

________________________________________ ________________________________ _________________________________________________

Name of Organization Official

Title

Signature

D

APPLICANT SIGNATURE

I certify that all information given on this application is TRUeAND CORReCTand that when I cease to be a member of the above named organization, I will

immediately return the registration plate to PennDOT.

_______________________________________________________________________________________

_________________________________

Applicant’s Signature in Ink

Date

GENERALINFORMATION REGARDINGASPECIALORGANIZATION PLATE

•PennDOT charges an issuance fee of $25. Participating organizations may charge an additional fee above the $25 PennDOT fee. The organization fee is $________________. Therefore, the total fee due with this application is $________________. Fees must be made payable to the organization name of

______________________________________________________________________________________________________________________________.

•Payment is to be made by check or money order payable to Commonwealth of Pennsylvania. DO NOT SEND CASH. NO REFUND of the fee will be issued when an applicant cancels a request after an order is placed.

•No special organization registration plate will be duplicated. If your plate is lost, stolen or defaced you will need to reapply for a special organization registration plate by completing this application and submitting with the appropriate fees. Should you need an immediate replacement plate, please complete and submit Form MV-44, “Application for Duplicate Registration Card, Replacement of Registration Plate, Renewal Sticker or Weight Class Sticker," with a fee of $11.A standard issued plate will be issued until the replacement special organization registration plate can be provided. (NOTE: Form MV-44 is available on our website at www.dmv.state.pa.us.)

•Requests for special organization registration plates are restricted to passenger vehicles, trucks with a registered gross weight of not more than 14,000 lbs., motor homes, and trailers. Motorcycles do not qualify for special organization registration plates.

•This application, completed in full, along with a check or money order should be mailed to: Bureau of Motor Vehicles, Special Organization Plate Program, P.O. Box 68266, Harrisburg, PA17106-8266.

•When the applicant ceases to be a member in the organization or ceases to be a notary public as listed in Section B, the registration plate must be returned to PennDOT. Complete Form MV-44 and submit a fee of $11 for the issuance of a regular series registration plate.

•This special organization registration plate is issued in number sequence only and may not be personalized.

•All telephone numbers will be held in confidence and used only in the event of a problem with your application.

•To avoid possible problems with citations with your old registration plate, return it to: Bureau of Motor Vehicles, Return Tag Unit, P.O. Box 68597, Harrisburg, PA 17106-8597 after you have received your special organization plate.

SPECIALINSTRUCTIONS - SECTION C

•If the applicant is a notary applying for a notary public plate, the applicant’s notary seal must be affixed in this section instead of an official’s signature.

Visit us at www.dmv.state.pa.us or call us at:

In state: 1-800-932-4600 u TDD: 1-800-228-0676 u Out-of-State: 1-717-412-5300 u TDD Out-of-State: 1-717-412-5380