APPLICATION FOR PERSONALIZED PLATES - Alaska

1 STATE OF Alaska DIVISION OF MOTOR VEHICLES APPLICATION FOR PERSONALIZED PLATES Form 803 (Rev. 10/29/2018) 803 VEHICLE AND OWNER INFORMATION FIRST NAME MIDDLE NAME LAST NAME CURRENT PLATE OR SERIAL NUMBER (VIN) MAKE MODEL MAILING ADDRESS CITY STATE ZIP CODE EMAIL ADDRESS PHONE NUMBER I WANT TO RECEIVE NOTIFICATIONS BY: E- MAIL MAIL Use ONLY the following characters: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 1 2 3 4 5 6 7 8 9 If a space is desired between characters, leave the block blank. 1ST CHOICE MEANING: (This helps speed up the approval process for your plate) 2ND CHOICE 3RD CHOICE PLATE SIZE REQUESTED: LARGE (Car / Truck / Trailer) SMALL (Motorcycle / Trailer) GENERAL AVAILABILITY DESIGNS STANDARD PLATES - $30 BEAR* CARIBOU MOUNTAIN BLUE / GOLD*Bear will appear in center of plateUNIVERSITY PLATES - $50 UAA UAF UAS PWSCCSUPPORT PLATES (Fees vary) NRA ($50 initially + $30 on renewal) CHOOSE LIFE ($30 initially + $30 on renewal) IN GOD WE TRUST ($30 initially + $30 on renewal) SUPPORT OUR TROOPS ($40 initially + $40 on renewal) PRO-FAMILY, PRO- CHOICE ($30 initially + $30 on renewal) COMMEMORATING VETERANS ($100 initially+ $35 on renewal) BREAST CANCER AWARENESS ($50) BLOOD BANK OF Alaska ($50) CELEBRATING THE ARTS ($30) CHILDRENS TRUST ($100)

2 SPECIALIZED PLATES See back for additional requirements MEMBERSHIP PLATES - $50 FREEMASON LIONS CLUB KNIGHTS OF COLUMBUS IDITAROD FINISHER INTERNATIONALASSOCIATION OF FIREFIGHTERS (IAFF) PIONEERS OF ALASKASPECIAL PROGRAM PLATES FIRE FIGHTER / EMS ($30) AMATEUR RADIO ($0 for ablue/gold plate, must read andinitial back of form)MILITARY PLATES - $30 ARMY NAVY MARINES AIR FORCE COAST GUARD NATIONAL GUARD LAO VETERAN PRISONER OF WAR PURPLE HEART PEARL HARBOR SURVIVOR GOLD STAR FAMILY DISABLE VET W/ PRIVILEGES DISABLE VET NO PRIVILEGES UNIT EMBLEM (Fill in Unit) _____By signing below, I swear, under the penalty of perjury, that everything on this APPLICATION is true and correct, and that I meet all of the legal requirements and qualifications for the plate requested. Signature Date By signing below as the Authorizing Individual I am certifying, under penalty of perjury, that the applicant above meets all of the legal requirements and qualifications for the plate requested and that I am an appropriate authorizing party, as detailed on the back of this form.

3 Authorizing Individual (Signature, Printed Name, Title/Rank) Date DMV USE ONLY: NEW CLASS CODE DATE BATCH LOGIN ID / OFFICE FEE: CA CC CK Form 803 (Rev. 10/29/2018) PLATE REQUIREMENTS ARMY / AIR FORCE / MARINE / NAVY / COAST GUARD / UNIT EMBLEM You must present a DD214, verification letter from the Veteran s Administration, Active Duty ID card, Retiree ID Card, or a current Leave and Earnings Statement (LES). NATIONAL GUARD All actively-serving members of the Alaska National Guard are eligible for this plate. You must show your Military ID and provide a copy of page one from your Virtual Military Personnel Flight (Air) or your Personnel Qualification Record (Army). GOLD STAR Available to the parent, guardian, brother, sister, dependent, or spouse (unless remarried) of a member of the United States armed forces that was killed in the line of duty.

4 You must present a copy of the Report of Casualty (DD1300) from the US Dept. o f Veterans Affairs proving you are a qualified family member of the military member killed in the line of duty. If you are not listed as a relative on the DD1300, you must present other documentation to prove eligibility. LAO VETERAN Available to veterans of military operations in support of the US in the Kingdom of Laos between 2/28/1961 and 5/15/1975. Present one of the following: A document issued by the US Military during the required period showing membership in a service with a special guerrilla unit or irregular forces in Laos; An affidavit from your superior officer or non-commissioned officer; An affidavit from another individual that also served in an appropriate unit and has personal knowledge of your service, or from a family member of an individual who personally knew of your service; A signed Congressional Commendation for Vietnam War Service in Laos; A commendation issued by the government of South Vietnam; A pay record from the appropriate time period; An identification card from the Lao Veterans of America, Inc.

5 , SGU Veterans and Families of USA, Inc. or other organization that requires documentation of service. AMATEUR RADIO OPERATOR Available to Alaskans that hold a valid FCC amateur radio operator s license AND carry an amateur radio transmitter in their vehicle. Must present a copy of current FCC license. Please initial below: _____ I certify my FCC license meets the requirements set forth in AS (i). _____ I certify my vehicle is equipped with an antenna, a power supply and wiring that are a permanent part of the vehicle as outlined in AS (d) (8) (A) & (B) and that I qualify for free registration under this statute. FIREFIGHTER / EMS All active members and former members with at least 5 years of service in Alaska as a fire fighter or EMS provider. This form must be signed by your Chief Officer or authorized representative on the line marked Authorizing Individual.

6 If no longer active, you must instead present documentation demonstration 10+ years of service as a fire fighter or EMS provider in the State of Alaska . FREEMASONS / LIONS CLUB / KNIGHTS OF COLUMBUS / INTERNATIONAL ASSOCIATION OF FIRE FIGHTERS/ PIONEERS OF Alaska / Applicants must submit evidence of current membership for the organization. IDITAROD FINISHER Must present a letter from the Iditarod Trail Committee identifying you as an Iditarod Finisher. DISABILITY PLATES Must present a Special Disability Parking Permit (Form 861) indicating a permanent disability, to apply for any of the disability PLATES with parking privileges OR submit certification from Veteran's Affairs (VA) stating you have a service-related disability of 50% or more to qualify for a Disabled Veteran's Plate (with or without wheelchair logo parking privileges). CELEBRATING THE ARTS Special request Celebrating the Arts PLATES change every 2 years.

7 The PLATES fees collected may be appropriated by the legislature to programs benefiting the arts.