APPLICATION FOR PERSONALIZED, AMATEUR RADIO …

1 PERSO naliZED REGiStRatiOn PlatE inFORMatiOnDaytime Telephone NumberHome _____Office _____aaPPlicant anD VEHiclE inFORMatiOn - List Information Currently Shown on Title or Registration RADIO OPERatOR REGiStRatiOn PlatE inFORMatiOnDPRESS PHOtOGRaPHER REGiStRatiOn PlatE inFORMatiOnMake of VehicleRegistration Plate NumberExpiration DateThe number of allotted letters or numbers in combination varies depending on the selected registration plate type. Please see the reverse side of thisapplication for additional instructions regarding the allotted spaces. No other special characters are available. Please use capital letters and print clearly. FIRST CHOICESECOND CHOICETHIRD CHOICEEXaMPlES ..I am the holder of a valid AMATEUR RADIO Station License (copy must be attached) issued by the Federal Communications Commission dated _____ and have been assigned call letters _____.

2 I certify that I am employed full time by _____as a newspaper, newsreel or television news photographer. The motor vehicle for which the Press Photographer registration plates are requestedwill be used in pursuit of my regular employment in covering news certify that _____ is employed as a newspaper, newsreel, ortelevision news OF FIRMSTREET ADDRESSSTATEZIP CODECITYTHE FOLLOWING INFORMATION IS TO BE COMPLETED BY THE EMPLOYERSIGNATURE OF EMPLOYERPRINTED NAME OF EMPLOYERDATESIGNATURE OF OWNER OR AUTHORIZED SIGNERSIGNATURE OF CO-OWNERDATEEaPPlicant(S) SiGnatUREI/We certify that all information given on this APPLICATION is TRUE and : In conjunction with replacement of your registration plate, you will receive one registration card. If additional registration cards are desired,the fee is $2 for each of duplicate registration cards requested @ $2 each U l l - D O GS P a c Ec R E 8 i V E W E l 0V E UnOtE:When requesting a numeric character of zero, please show as "0" instead of the alpha character "O.

3 " Since this is an electronically fillableform, after printing the form, please be sure any zero is marked with a "/."MV-904 (12-17) APPLICATION FOR PERSO naliZED, AMATEUR RADIO OPERatOR OR PRESSPHOtOGRaPHER REGiStRatiOn PlatEFor Department Use OnlyBureau of Motor Vehicles PO Box 68293 Harrisburg, PA 17106-8293Co-Owner Last NameFirst NameMiddle Name PA DL/Photo ID#Date of BirthLast Name (or Full Business Name)First NameMiddle NamePA DL/Photo ID#or Bus. ID#Date of BirthStreet AddressCityStateZip CodeVehicle Identification NumberTitle NumberCHECK BLOCK FOR TYPE OF REGISTRATION PLATE DESIRED:qPersonalized Registration Plate- Complete Sections A, B and E. Fee: $79qamateur RADIO Operator Registration Plate- Complete Sections A, C and E. Fee: $11qPress Photographer Registration Plate- Complete Sections A, B (if applicable), D and E Fee: $11(An additional $104 fee forpersonalization.)

4 InFORMatiOn Standard personalized registration plates, including passenger car, truck, trailers, etc., may contain up to SEVE nletters and numbers in combination. Only one hyphen or space is permitted, but not both. If no hyphen or spaceis requested, one block will remain blank. Please use capital letters and print clearly. When requesting a numericcharacter of zero, please list as "0" instead of the alpha character of "O." Since this is an electronically fillableform, after printing the form, please be sure any zero is marked with a "/." nOtE:A hyphen or space is notrecognized as part of the registration plate configuration and does not count as one of the letters or extra box is provided if you wish to include a hyphen or space as part of your configuration.

5 Motorcyclepersonalized registration plates may contain up to FiVEletters or FiVEletters and numbers incombination. If a hyphen or space is used as part of the registration configuration, it counts as one of theavailable spaces for personalization. Only one hyphen or space is permitted, but not both. No additional specialcharacters are available. Please use capital letters and print clearly. When requesting a numeric character of zero,please list as "0" instead of the alpha character of "O." Since this is an electronically fillable form, after printing theform, please be sure any zero is marked with a "/." Motor Homepersonalized registration plates may contain up to SEVE nletters and numbers in a hyphen or space is used as part of the registration configuration, it counts as one of the available spacesfor personalization.

6 Only one hyphen or space is permitted, but not both. No additional special characters areavailable. Please use capital letters and print clearly. When requesting a numeric character of zero, please list as"0" instead of the alpha character of "O." Since this is an electronically fillable form, after printing the form, pleasebe sure any zero is marked with a "/." Mopedpersonalized registration plates may contain up to FiVEletters and numbers in combination. If ahyphen or space is used as part of the registration configuration, it counts as one of the available spaces forpersonalization. Only one hyphen or space is permitted, but not both. No additional special characters areavailable. Please use capital letters and print clearly. When requesting a numeric character of zero, please list as"0" instead of the alpha character of "O.

7 " Since this is an electronically fillable form, after printing the form, pleasebe sure any zero is marked with a "/." Omnibuspersonalized registration plates may contain up to FiVEletters and numbers in combination. If ahyphen or space is used as part of the registration configuration, it counts as one of the available spaces forpersonalization. Only one hyphen or space is permitted, but not both. No additional special characters areavailable. Please use capital letters and print clearly. When requesting a numeric character of zero, please list as"0" instead of the alpha character of "O." Since this is an electronically fillable form, after printing the form, pleasebe sure any zero is marked with a "/." nOtE:A pre-printed letter configuration of OB will precede yourpersonalized configuration on your registration plate and cannot be changed.

8 NOtE:The Keystone emblemdoes not appear on personalized registration plates. Permanent trailerregistration plates may contain up to FOUR letters or numbers in combination. If a hyphen orspace is used as part of the registration configuration, it counts as one of the available spaces for one hyphen or space is permitted, but not both. No additional special characters are available. Please usecapital letters and print clearly. When requesting a numeric character of zero, please list as "0" instead of thealpha character of "O." Since this is an electronically fillable form, after printing the form, please be sure any zerois marked with a "/." nOtE:A pre-printed letter configuration of Pt will precede your personalized configurationand an "a"will follow your personalization configuration on your registration plate and cannot be :The Keystone emblem does not appear on personalized registration RADIO OPERatOR RADIO and television stations may be issued personalized registration plates containing the station call letters assigned by the Federal Communications Commission (FCC).

9 One registration plate will be issued with your FCC assigned call sign. If you desire a second AMATEUR RADIO Operator registration plate, your FCC call sign plus a hyphen and the #2 will be issued. A copy of your AMATEUR RADIO Station License must be attached. no other personalization is available. Fee is $ PHOtOGRaPHER Issued to a person who is employed full time as a newspaper, newsreel, or television photographer or cameraman. The vehicle must be registered in the name of the press photographer or jointly by the press photographer and aco-owner. Only one set of press photographer registration plates will be issued to any applicant. Fee is $11. nOtE:An additional $104 fee is due if requesting personalization of the Press Photographerregistration plate Press Photographer personalized registration plates may contain up to tHREE letters and numbers incombination.

10 If a hyphen or space is used as part of the registration configuration, it counts as one of the availablespaces for personalization. Only one hyphen or space is permitted, but not both. No additional special charactersare available. Please use capital letters and print clearly. When requesting a numeric character of zero, please listas "0" instead of the alpha character of "O." Since this is an electronically fillable form, after printing the form,please be sure any zero is marked with a "/." nOtE: A pre-printed letter configuration of PP will precede yourpersonalized configuration on your registration plate and cannot be inFORMatiOn PennDOT reserves the right to limit or reject certain requests. Personalized registration applicants must have a valid registration plate which the applicant shall retain pending receipt of the requested personalizedregistration plate.