www.dmv.pa.gov APPLICATION FOR SPECIAL FUND …

1 PlEasE CHECK (3) TYPE OF rEgIsTraTION PlaTE rEquEsTED- See reverse side for picture of registration plateand additional Wild Resource Conservation fund (IY) - Fee: $36 ($15 from the fee goes toward the designated fund and an additional $104 is required for personalization.)r Pennsylvania Zoological Council fund (HR) - Fee: $55($23 from the fee goes toward the designated fund and an additional $104 is required for personalization.)r Preserve Our Heritage (L6) - Fee: $55($23 from the fee goes toward the designated fund .) NOTE:This full color registration plate is not available for Pennsylvania Monuments (IM) - Fee: $55($23 from the fee goes toward the designated fund and an additional $104 is required for personalization.)a VEHIClE DEsCrIPTION aND aPPlICaNT INFOrMaTION- Complete this section exactly as information appears on current registration NumberLast Name (Or Full Business Name)Street AddressVehicle Identification NumberRegistration Plate NumberExpiration DateMake of VehicleYearFirst NameMiddle NameCityStateZip CodeTelephone Number: (Home) ( ) _____ (Work) ( ) _____NOTE: In conjunction with replacement of your registration plate, you will receive one registration card.

2 If additional registration cards are desired, the feeis $2 for each of Duplicate registration Cards requested @ $2 each DL/Photo ID#or Bus. ID#Date of Birth Signature of Applicant DateI/We hereby certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I/we understand that any misstatementof fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Section 4904[b]).Signature of Co-Applicant DateCo-Owner Last Name First Name Middle Name PA DL/Photo ID# Date of BirthMV-911 (10-17) APPLICATION FOR SPECIAL FUNDREGISTRATION PLATEFor Department Use OnlyBureau of Motor Vehicles Box 67900 Harrisburg, PA 17106-7900 FIRST CHOICESECOND CHOICETHIRD CHOICEC aPPlICaNT sIgNaTurEB OPTIONal PErsONalIzaTION request (NOTE:Additional $104 Fee Required.)

3 Personalized SPECIAL fund registration plate choices may contain up to FIVE letters or numbers in combination. Pre-printed letter configurations ordesignated letter(s) appear on personalized registration plates based on the type of registration plate see the reverse side ofthis APPLICATION for additional information. Only one hyphen or space is permitted as part of the available spaces for otherspecial characters are available. Please use capital letters and print clearly. NOTE:The full color Preserve Our Heritage registration plate is notavailable for One:Leased Vehicle: rYes rNo NOTE:If the vehicle is a leased vehicle, Form MV-1L, APPLICATION for LesseeInformation, must be completed and attached. Form MV-1L is available on our website at :When requesting a numeric character of zero, please show as " " instead of the alpha character "O.

4 " Since this is an electronically fillableform, after printing the form, please be sure any zero is marked with a "/."Preserve Our HeritageBenefits the educational and exhibit programs of the Pennsylvania Historical and Museum can have your very own registration plate commemorating Pennsylvania's proud railroading heritage. Whether youlove trains, appreciate fine art, or like a unique registration plate, you ll want this distinctive PennDOT registration plate thatfeatures Grif Teller s famous 1928 painting When the Broadway Meets the Dawn. The painting depicts the PennsylvaniaRailroad s Broadway Limited on its Chicago to New York run as the first light of day breaks along the Juniata River incentral Pennsylvania. The registration plate reproduces the rich, deep colors of Teller s original work of art, capturing thepower and speed of the onrushing locomotive.

5 The Pennsylvania Railroad played a key role in making the commonwealtha leader in the railroading industry. The Pennsy story comes alive at the world-class Railroad Museum of Pennsylvaniain Strasburg, Lancaster County, and in the collections of the State Archives of Pennsylvania in Harrisburg. Your supportwill help underwrite the educational and exhibit programs of the Pennsylvania Historical and Museum Commission. Thisregistration plate is not available for personalization at this zoological Council FundBenefits the Philadelphia Zoo, the Pittsburgh Zoo, the Erie Zoo, the National Aviary in Pittsburgh, the Elmwood Park Zoo in Norristown and the Lehigh Valley can own a vehicle registration plate that helps save endangered wildlife and lets you show your support for zooswherever you drive.

6 Created by the Zoological Council, this registration plate pictures one of the most magnificent andendangered animals in the world - the Siberian Tiger. The Pennsylvania Zoological Council is comprised of six institutions:The Philadelphia zoo; the Pittsburgh zoo; the Erie zoo; the National aviary in Pittsburgh; the Elmwood Park zooin Norristown; and the lehigh Valley institution is devoted to animal conservation and education from the sale of the registration plates will directly support these groups and their important projects, which includecaptive breeding of endangered species; creating bird sanctuaries on recovered wetlands; providing community educationprograms; constructing exciting interactive exhibits, and reintroducing endangered species into the wild. Purchase the zooregistration plate, and you immediately add your support to the efforts of the Pennsylvania Zoological Council.

7 You ll alsoshow others your love for wild PersonalizedPennsylvania zoological Council Fundregistration plates, up to FIVE letters and/or numbers may be used in combination. If a hyphen orspace is used as part of the registration configuration, it counts as one of the available spaces for personalization. Only one hyphen or space is permitted, but notboth. No additional SPECIAL characters are available. Please use capital letters and print clearly. When requesting a numeric character of zero, please show as " "instead of the alpha character "O." Since this is an electronically fillable form, after printing the form, please be sure any zero is marked with a "/." A pre-printedletter configuration of Pz will follow your personalized configuration on your registration plate and cannot be MonumentsBenefits the Veterans Trust the Pennsylvania Monuments registration plate and show your support for the cleaning, repair and restorationof Pennsylvania monuments.

8 The registration plate pictures the Pennsylvania Memorial Monument found at the GettysburgNational Military Park and displays the words Gettysburg 1863. Proceeds from the sale of this registration plate godirectly to the Veteran Trust fund and will be used exclusively to provide grants to nonprofit organizations for the cleaning,repair and restoration of Pennsylvania Monuments by the Gettysburg National Military PersonalizedPennsylvania Monumentsregistration plates, up to FIVE letters and/or numbers may be used incombination. If a hyphen or space is used as part of the registration configuration, it counts as one of the available spacesfor personalization. Only one hyphen or space is permitted, but not both. No additional SPECIAL characters are available. Please use capital letters and printclearly.

9 When requesting a numeric character of zero, please show as " " instead of the alpha character "O." Since this is an electronically fillable form, afterprinting the form, please be sure any zero is marked with a "/." A pre-printed letter configuration of "gB" will follow your personalized configuration on yourregistration plate and cannot be the Following SPECIAL registration Plate(Please Check Type of Registration Plate Requested on Front Side of Form)Plate Colors - Blue, white and yellowPlate Colors - Blue, white and yellowSAMPLESAMPLEP late Colors - Brown, orange, red and whiteWild resource Conservation fund (WrCF)Benefits the Management and Conservation of the Commonwealth s Flora and Fauna. You can own a vehicle registration plate that helps support the management of our wild resources to include protecting PAwildlife (which describes all forms of wildlife that are not pursued by hunters, furtakers or anglers).

10 The number of birds,animals, fish, reptiles, and amphibians in this protected wildlife category represents 80 percent of all wildlife in PA. The WildResource Conservation Board has the responsibility of selecting studies and projects recommended by the state sresource agencies, Department of Conservation and Natural Resources, PA Fish and Boat Commission, and PA GameCommission. Through generous donations, the Wild Resource Conservation Board has been able to fund many projectsincluding reestablishing the River Otter, reintroducing the osprey, and generating a computer database of endangered andthreatened species in PA. WRCF is funded entirely by donated funds from the state tax check-off, direct contributions, andfrom the sale of this registration PersonalizedWild resource Conservation fund (WrCF)registration plates, up to FIVE letters and/or numbers may be used in combination.