New York State Department of Motor Vehicles PROFESSIONAL SERIES CUSTOM PLATES In New York State, custom plates are reserved for easy identification of vehicles owned by members of professional groups. They are subject to the following regulations: your current registration must be in the name of the professional person; and you must provide a copy of your current NYS Department of Education (DOE) Registration Certificate with your order. PLATE SERIES REQUESTED (First-time plate fees are listed after each series and do not include the registration fee): Acupuncturist (ACU) Chiropractor (DCH) Dentist (DDS) Medical Doctor (MD) Optometrist (OD) Pharmacist (RX) Physical Therapist (PT) Podiatrist (DPM) Professional Engineer (PE) Psychologist (PSY) Registered Architect (AR) Registered Nurse (RN) Registered Physician’s Assistant (RPA) Veterinarian (VM) Visiting Nurse (VN) $60.00 each set (allowed more than one set) NYS Dental Association (DDS) NYS Dental Association (DMD) (Provide proof of membership in NYSDA) (Provide proof of membership in NYSDA) Certified Public Accountant (CPA)* Chiropractor (DC)* Hypnotherapist (HT)* (Provide proof of membership in NYSHA) REQUIRED Choice 1 __ __ __ __ __ __ $58.75 each set *Only the three series shown to the left can be personalized, using as many as 6 $60.00 each set spaces. The fee to order one of these personalized plates is $91.25. Write 3 plate number choices below. If you want to leave a space on the plate, put a period(.) on the line where the space should be. If the ISA is required, only 5 spaces are allowed. Choice 2 __ __ __ __ __ __ Choice 3 __ __ __ __ __ __ For personalized plate combinations only. You must explain the meaning of your letter/number combination. DMV reserves the right to reject, recall or cancel any plate that is deemed objectionable. This includes plates that have already been issued. 1st Choice ________________________________________________________________________________________________ 2nd Choice _________________________________________________________________________________________ 3rd Choice ________________________________________________________________________________________________ FILL IN INFORMATION BELOW (Please Print): Last Name First MI Mailing Address (Street & No., Apt. No.) State Professional License No. Date of Birth / State City Business Address Zip Code Zip Code Daytime Phone No. / ( Signature (Sign Name in Full) ) Date  Current Plate Number Vehicle Year If you need the International Symbol of Access on your new plates and you do not have it on your current plates, you Do your current plates have the International Symbol of Access? Payment Method: Check Vehicle Make Yes Money Order No must also submit a completed form MV-664.1 MasterCard Visa American Express Discover Amount Enclosed Name (as it appears on credit card) _______________________________________________________________ $ Card Account Number ____________________________________________ Expiration Date ____________________________________ Authorized Signature  __________________________________________________________________________ Please do not send cash! Make check or money order payable to “Commissioner of Motor Vehicles”. Please allow 4 to 6 weeks for delivery. The annual renewal fee for professional series custom plates (except NYS Dental Association plates) is $31.25 ($62.50 for CPA or DC or HT personalized plates). The annual renewal fee for NYS Dental Association plates is $30.00. These fees are in addition to your vehicle registration renewal fee. You will be billed for the plates every two years when you renew your registration. NOTE: Plates are not ordered until we receive ALL required documents and fees. The next available number in the plate series will be assigned. Falsifying documents will result in cancellation of the custom plates. Plates will be mailed to the address on the vehicle’s registration file. If you have moved and you have not updated your address on your registration record, please complete the Change of Address form MV-232. IMPORTANT: Making a false statement in any registration application or in any proof or statements in connection with it, or deceiving or substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in the revocation or suspension of the registration and/or the applicant’s license pursuant to regulations established by the Commissioner. The act of renewing these plates shall constitute your certification that you remain eligible to continue holding these plates. MV-410 (2/11) If you have any questions, or need additional information, call 518-402-4838. --- www.dmv.ny.gov --Return this completed form, the required proof and your payment to: Department of Motor Vehicles, Custom Plates Unit, PO Box 2775, Albany NY 12220. American LegalNet, Inc. www.FormsWorkFlow.com