REQUEST FOR PERSONALIZED (PRESTIGE) LICENSE PLATE

1 LOUISIANA DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONS. OFFICE OF MOTOR VEHICLES. BOX 64886. BATON ROUGE, LOUISIANA 70896-4886. REQUEST FOR PERSONALIZED ( prestige ) LICENSE PLATE . Visit our website or call 225-925-6146. Date of Application _____. Vehicle Identification Number _____. DO NOT WRITE IN ABOVE BLOCK. Name Address City, Parish and State Zip Code Make Model Body Style Year Driver's LICENSE No. Color of Vehicle Present LICENSE No. on Vehicle Expiration Owner's Signature Show 3 choices, in order of preference 1ST CHOICE 2ND CHOICE 3RD CHOICE. Phone (_____)_____. _____. DO NOT USE THIS SPACE. PERSONALIZED prestige PLATE Fees _____. Present LICENSE PLATE Number _____. This is your official receipt for PERSONALIZED prestige PLATE _____.

2 It takes approximately 4 months for the PLATE to be manufactured. This receipt must be surrendered to the _____. Motor Vehicle Office when you are notified to pick up your PLATE . The PLATE will be mailed to the address shown above. _____ _____. Date Motor Vehicle Analyst DPSMV 1619 (R 02/10).