Free Civilian license pates application - Wisconsin

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CIVILIAN LICENSE PLATE APPLICATION
MV2652 4/2007 s.341.14(6r) Wis. Stats.

Wisconsin Department of Transportation

Check group to be shown on plate: Firefighter Rescue Squad Member Emergency Medical Technician - EMT 1st Choice 2nd Choice
Meaning Meaning

____ I would like nonpersonalized Civilian plates. ____ I would like personalized Civilian plates. Note: If all personalized choices have been used: ____ I would like standard Civilian plates. ____ Call me at the telephone number below. ____ E-mail me at ________________________

Meaning

3rd Choice
Give information for the vehicle that you wish to register with Civilian plates.
Current License Plate # Year - Make Body Type Vehicle Identification #

Owner(s)/Lessee Name (Last, First, M.I.) - Print

Social Security # or Driver License # or (If company owned) FEIN #

Street Address

Telephone # where you may be reached 7 a.m. to 4:30 p.m.

City

State

ZIP Code

The social security number is used for purposes authorized by law.

(Applicant Signature)

Proof of Eligibility
All documentation is subject to verification by the Department. Emergency Medical Technician please submit a photocopy of your current EMT license: EMT - Basic EMT - Intermediate Technician

Firefighter or Rescue Squad Member, please submit: 1. A letter on official letterhead signed and dated by the Chief, or other authorized person of your employing fire department. or 2. The following information completed, signed and dated by appropriate personnel.

(Employing Fire Department Name)

X
EMT - Intermediate EMT - Paramedic
(Signature of Fire Chief or Authorized Person) (Date)

(Print or Type Name)

Release of Personalized Plates Release of Nonexempt Information
I authorize the reissuance of my personalized license plate number specified above to applicant shown above. I allow the Department of Transportation to reissue my current personalized plate after it is replaced with a different plate. The Wisconsin Department of Transportation uses the information on this form to issue Civilian plates. Under open records laws, the Department must make nonexempt information available upon request. Do you want your name withheld from mailing lists of 10 or more individuals?

X
(Signature of Owner Releasing Plate)

Yes. No.

This will remove your name from marketing lists.

New Owner - please check one:
Have plates in good condition in my possession Need new plates issued Note: No credit of registration fees or personalized plate fee from former owner is allowed.
Print

ADA - The Wisconsin Department of Transportation complies with the Americans with Disabilities Act.

HOW TO APPLY

1. To order nonpersonalized Civilian plates, mark application and omit steps 2-4. 2. To order personalized Civilian plates, choose 1-6 characters. If you choose 6 characters, no spaces are allowed.

General Information
When you request Civilian plates, you pay: An annual $15.00 personalized plate fee OR a $15.00 original issuance fee. Your regular registration fee, if your current plates expire within 3 months. Personalized Civilian Plates If your personalized request is not available, on the form, check which option you would like us to follow. WisDOT may refuse to issue or recall after issuance, a request that is misleading or may be offensive to good taste or decency. No refund or adjustment will be made for a change of choice or spacing after the plate has been ordered, or if the application is unclear or incorrectly completed. Plates will be mailed 4-6 weeks after you receive a new Certificate of Registration. Plates Required in 2 Days To legally operate your vehicle, you must display license plates within two business days of purchase. If you do not have current plates, apply to a DMV Customer Service Center or an agent authorized by DMV to obtain a temporary plate while your Civilian plate order is processed. An agent may charge a $3 plate fee and / or may also charge a $5 service fee. First Responders do not qualify If you have questions: * Call: 608-266-3041 * E-mail: [email protected] * FAX: 608-267-5106 * Write to the address given.

R E S C U E
If you choose 5 characters, you may request up to 2 spaces between any of the characters. Indicate this request with diagonal lines as shown here.

I M E M T
3. Use capital letters or numbers. The letter O and the number zero are the same. The following are not acceptable: small letters, symbols, signs, hyphens, apostrophes, etc. Carefully distinguish between: Letters L or I and Number 1 Letter Z and Number 2 Letter S and Number 5 Letter B and Number 8 Letter G and Number 6 Letter U and Letter V 4. Provide meaning of request, i.e., what does this represent? 5. If the vehicle that you wish to register with Civilian group plates is already titled in your name, send: * A copy of your Certificate of Registration OR complete the vehicle description on the application; * $15.00 issuance or personalized plate fee, plus the annual registration fee if the current plates expire within the next 3 months. 6. If the vehicle is NOT titled in your name, send: * A completed title application (MV1 or MV11); * All required fees, including annual registration fee; * Additional $15.00 issuance or personalized plate fee. 7. Send this application with signed "Proof of Eligibility" or photocopy of eligibility documentation. 8. Make check or money order payable to: Registration Fee Trust. 9. Mail all required items to: Wisconsin Department of Transportation Special Plates Unit PO Box 7911 Madison, WI 53707-7911.

Civilian License Plate Application
Who is eligible?
An owner, lessee, or trust beneficiary who is: t A Firefighter t A Rescue Squad Member t A Wisconsin-licensed Emergency Medical Technician - EMT
t Automobile t Motor Home (annual registration only) t Truck t 4,500, 6,000 or 8,000 pound gross weight including dual purpose farm and dual purpose motor home t 12,000 pound gross weight farm truck
MV2652 Wisconsin Department of Transportation

Civilian Plates are available for: