1716 - Missouri Application for Specialty and Personalized ...

1 Reset Form Print Form Missouri Department of Revenue Form Application for Missouri Personalized 1716 and Special License Plates Any false statement in this Application is a violation of the law and may be punished by fine or imprisonment or both. Name must appear as shown on vehicle title (Please check which category of license plate you need). Owner's Name r Passenger r Recreational Vehicle (motor home). r Beyond Local 6 Truck r Local 6 Truck (limited to a 50 mile radius). Street, RR, or Box Number r Beyond Local 12 Truck r Local 12 Truck (limited to a 50 mile radius). Step 1. r Beyond Local 18 Truck r Local 18 Truck (limited to a 50 mile radius). City State ZIP Code r Beyond Local 24 Truck r Local 24 Truck (limited to a 50 mile radius).

2 R Motorcycle r Motortricycle r Check here to add this symbol to your plate. (Form 1776, Physician's Daytime Phone Number Current Plate Number Statement for Disabled Person's License Plates is required. See back (__ __ __)__ __ __-__ __ __ __ __ __ __ __ __ __ for more information.). Submit fee shown below with this Application . r Friends of Arrow Rock ($15) r Missouri Stream Team Coalition ($15). r Regular Personalized ($15) r God Bless America ($15) r Missouri Task Force 1 ($15). (Can be reserved at ) r Greek Collegiate Organization ($15) r Missouri Travel Council ($15). r amateur Radio ($15) _____ r MKN Conference of Teamsters ($15). r American Heart Association ($15) r Hearing Impaired Kids Endowment Fund ($15) r MO-AG Businesses ($15).

3 R American Legion ($15) r Helping Schools ($15) r Order of the Arrow ($15). r Be An Organ Donor ($15) r I'm Pet Friendly ($15) r Paramedic ($15). r Breast Cancer Awareness ($15) r Jefferson National Parks Association ($15) r Prince Hall ($15). r Cave State ($15) r Kingdom of Calontir ($15) r Professional Sports Team ($15). r Children's Trust Fund (Stock) ($15) r Knights of Columbus ($15) r St. Louis Blues r St. Louis Cardinals r Children's Trust Fund ($15) r Lions Club (Stock) ($15) r Kansas City Chiefs r Kansas City Royals r Choose Life ($15) r Lions Club ($15) r Rotary International ($15). r Collegiate ($15) r Masonic Grand Lodge ($15) r Safari Club International ($15).

4 Name of College or University _____ r Masters ($15) r Search and Rescue ($15). Step 2. r Coroner's Office ($15) r Missouri 4-H ($15) r Shriners ($15). r Custom Vehicle ($15) r Missouri Association of Realtors ($15) r Special Olympics ($15). r Disabled Person ($15) r Missouri Bicycle & Pedestrian Federation ($15) r Street Rod ($15). r Don't Tread on Me ($15) r Missouri Botanical Garden ($15) r Tribe of Mic-O-Say ($15). r Ducks Unlimited ($15) r Missouri Conservation Heritage (Stock) ($15) r Kansas City District r St. Joseph District r Eagle Scout ($15) r Bird r Deer r Bald Eagle r Wilson Creek Battlefield ($15). r Eastern Star - Harmony Chapter ($15) r Missouri Conservation Heritage ($15) r Zoos ($15) r Kansas City r St.

5 Louis r Emergency Medical Technician ($15) r Bird r Deer r Bald Eagle r Shuttle Bus ($15) regular Personalized r Fight Terrorism ($15) r Missouri Elks Association ($15) r Vanpool ($15) regular Personalized r Firefighter (Stock) ($15) r Missouri Federation of Square & Round r Other _____. r Firefighter ($15) Dance Clubs ($15). r Former Legislator ($15) r Missouri Jaycee (Stock) ($15) Note: Please contact the Missouri Department Last Year Served _____ r Missouri Jaycee ($15) of Revenue for other Specialty plates r Fraternal Order of Eagles ($15) r Missouri Junior Golf Foundation ($15) that may be available. r Fraternal Order of Police ($15) r Missouri Remembers POW/MIA ($15).

6 For all plates listed as Stock, the Missouri Department of Revenue will select your license plate configuration. Personalized plate choices (complete only if applying for Personalized plates. Please include more than one choice.). Please use all capital letters and show choices in order of preference. Regular Personalized license plates may consist of no more than six characters plus a dash, a space, or an apostrophe. Personalized plates displaying an emblem or wheelchair symbol may consist of no more than six characters or five characters plus a dash, a space, or an apostrophe. Personalized plates displaying an emblem and wheelchair symbol are limited to four characters or three characters plus a dash, a space, or an apostrophe.

7 Personalized motorcycle or motortricycle plates may consist of no more than six characters or five characters plus a dash, space, or an apostrophe. Personalized motorcycle or motortricycle plates displaying an emblem or wheelchair symbol may consist of no more than five characters or four characters plus a dash, space, or an apostrophe. Personalized motorcycle/motortricycle plates displaying an emblem and wheelchair symbol may consist of no more than three characters or two characters plus a dash, space, or an apostrophe. The Missouri Department of Revenue will not issue plates that contain any letters, numbers, or a combination of letters and numbers which are obscene, profane, patently offensive or contemptuous of a racial or ethnic group, offensive to good taste or decency, or would present an unreasonable danger to the health or safety of the applicant, of other users of streets and highways, or of the public in any location where the vehicle with Step 3.

8 Such plate may be found. The Missouri Department of Revenue will not issue plates that conflict with the regular license numbering system. Vehicle Plate Will Year Make Model VIN Number Be Attached To __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __. First Choice Second Choice Third Choice Fourth Choice Fifth Choice Sixth Choice Description of what the configuration Description of what the configuration Description of what the configuration Description of what the configuration Description of what the configuration Description of what the configuration above stands for. above stands for. above stands for. above stands for. above stands for. above stands for.

9 Must be completed by all applicants. These license plates will not be mailed. Indicate name of license office where plates are to be picked up. Office Office Number I hereby certify under penalty of perjury that all information regarding this request is true and accurate and Step 4. is made without intent to defraud and that all statutory requirements for Personalized or special license __ __ __ plates have been met. I also acknowledge that, if the requested configuration is already issued for a vehicle I own, I must surrender those plates when I pick up the new plates bearing that configuration. Street City Signature of Owner or Applicant X Form 1716 (Revised 01-2017).

10 Regular Personalized plates can be reserved and ordered at applications must be completed, signed, and submitted with the fee noted on the front of the Application . The annual fee indicated on the Application is in addition to the regular registration fee set by law and is payable upon renewal. Depending on the type of license plates requested, additional documentation may be required as noted below. Make check or money order (do not send cash) payable to the Missouri Department of Revenue and forward with this Application to the address listed below. Note: The Missouri Department of Revenue may electronically resubmit checks returned for insufficient or uncollected funds.