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) 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)

2 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. 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.)

3 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. 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.

4 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., SGU Veterans and Families of USA, Inc. or other organization that requires documentation of service.

5 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 . 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 .

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