VSA 10 (01/10/2019) I certify that I am hearing impaired and cannot hear and understand normal speech. I am aware it is unlawful for any person who can hear and understand normal speech to obtain this license plate. Note: Due to the license plate design, personalization is not allowed for hearing impaired license plates. HEARING IMPAIRED CERTIFICATION LICENSE PLATE APPLICATION Purpose: Use this form to request souvenir, standard, personalized or special license plates. Instructions: Review the Additional Information Section on the back of this form. Mail completed form, with the appropriate fees, to DMV at the address above. Or, you may apply online at www.dmvNOW.com or at any DMV Customer Service Center or DMV Select office. APPLICATION TYPE (check one) VEHICLE LICENSE PLATES VEHICLE LICENSE PLATES - DISABLED SOUVENIR LICENSE PLATE TRANSFER EXISTING LICENSE PLATES LICENSE PLATE TYPE REQUESTED (check one) SCENIC (pick one) STANDARD LIGHTHOUSE HERITAGE (Dogwood-Cardinal) AUTUMN MOUNTAIN TO SEASHORE PATRIOTLocality: COLLEGE: (No initials or abbreviations) County City MILITARY: (No initials or abbreviations)(Note: some plates require certification)(Review the Clean Special Fuel License Plates section on the reverse side of this form.) SPECIAL INTEREST: (Organization Name - If organization has more than one license plate, specify design type) CLEAN FUEL Vehicle Year Make Model OTHER (Any plate not listed above) PERSONALIZED LICENSE PLATES: To request a personalized vehicle or souvenir plate, review the Personalized License Plates Policy on the reverse side of this form. Check this box and enter your choices below. PERSONALIZED LICENSE PLATE CHOICES 1st 2nd 3rd 4th DMV USE ONLY AVAILABLE CHOICE FEE $ APPLICANT INFORMATION CITY STATE ZIP CURRENT MAILING ADDRESS DAYTIME TELEPHONE NUMBER OWNER'S NAME (last)(first)(mi) DAYTIME TELEPHONE NUMBER CO-OWNER'S NAME (last)(first)(mi) PLATE TYPE PLATE EXPIRATION DATE CURRENT PLATE NUMBER VEHICLE IDENTIFICATION NUMBER VEHICLE TITLE NUMBER HEARING IMPAIRED LICENSE PLATE VSA 10 (01/10/2019) ADDITIONAL INFORMATION Special license plate fees can be $10, $15, or $25 annually or a one-time $10, $25 or $50 fee based on the plate design, in addition to the registration fees. Personalization is an additional $10 annually. If you are renewing early, the special license plate and/or personalized license plate fees will be prorated for the months remaining on your current vehicle registration. The Department of Motor Vehicles (DMV) will not honor a change of choice or refund after the order has been sent to the manufacturer. You may purchase samples of most special license plates. Personalized License Plates Policy All personalized character combinations are screened by DMV to ensure compliance with DMV's Personalized License Plate Policy. The combination of characters used to personalize a license plate must not violate DMV's Personalized License Plate Policy. DMV reserves the right to refuse and/or recall the issuance of any combination of objectionable characters if they, in any way, carry a connotation that may be reasonably seen by a person viewing a license plate as 1) profane, obscene, or vulgar in nature, 2) sexually explicit or graphic, 3) excretory related, 4) describing intimate body parts or genitals, 5) describing drugs, drug culture or drug use, 6) condoning or encouraging violence, and/or 7) describing illegal activities or illegal substances. In addition, Virginia Code 247 46.2-726 prohibits DMV from issuing to certain applicants any personalized character combination that can be read, interpreted, or understood to be a reference to children. Personalized license plates require special handling; allow up to 60 days for delivery. Plates will be mailed directly to the applicant. Indicate your choices in order of preference. The maximum number of characters allowed on standard and scenic license plates is 7 275. The maximum number of characters allowed on a heritage license plate is 6 275. Six characters are allowed on all other license plates bearing logos. License plates with logos may sometimes accommodate an additional 275 space when personalized. A blank space and a dash are the only two characters that are 275 characters. An ampersand is considered a full character. Spaces, dashes, and ampersands cannot be used consecutively. Visit our website www.dmvNOW.com to create a plate or ask a DMV representative to determine availability. New Special Interest License Plate Development Information All application and refund inquiries should be directed to the sponsor who is maintaining and facilitating collection of the 450 pre-paid applications for new license plates through General Assembly authorization or currently under development. When the 450 pre-paid applications are being processed, personalized license plate and special license plate fees are not prorated. Your vehicle registration will not be renewed unless it is within two months of expiration. Should your vehicle registration require renewal, you will be billed by DMV for payment. The entire special license plate process could take up to two years depending on the direction of the sponsor. It generally takes about nine months to develop a new plate once the 450 pre-paid applications are collected. Clean Special Fuel License Plates Clean special fuel plates do not allow free access to any Express Lanes without meeting the minimum passenger requirement. 240For free access to Express Lanes, drivers with clean special fuel plates must have the specified number of people in the vehicle and an E-Zpass Flex set to HOV mode. Not all vehicles qualify for the clean special fuel license plate. For a list of types of fuels that qualify a vehicle for clean special fuel plates, visit our website at www.dmvNOW.com. You can also email us with questions at CleanFuelPlates@dmv.virginia.gov . CERTIFICATION/SIGNATURES This vehicle is insured with liability coverage by a company licensed to do business in Virginia. Coverage must be in effect at the time of application and must This vehicle is not insured; therefore, I am remitting the applicable uninsured motor vehicle fee. This fee provides NO insurance coverage. remain in effect as long as the vehicle is registered, even if the vehicle is not driven or is inoperable. Failure to comply with Virginia's insurance requirements will result in suspension of your driver's license and vehicle license plates. I/We further certify and affirm that all information presented in this form is true and correct, that any documents I/we have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I/We make this certification and affirmation under penalty of perjury and I/we understand that knowingly making a false statement or representation on this form is a criminal violation. For a corporation, an authorized representative must sign. DATE (mm/dd/yyyy) CO-OWNER'S SIGNATURE DATE (mm/dd/yyyy) OWNER'S SIGNATURE POWER OF ATTORNEY FOR NON-RESIDENT(S) AND CORPORATION(S) NOT DOMICILED IN VIRGINIA: Pursuant to the provisions of Virginia Code 24746.2-601, I/we appoint the Commissioner of the Department of Motor Vehicles of the Commonwealth of Virginia, to be my/our true and legal agent upon whom all legal processes against me/us may be served in any legal proceeding arising from the operation and/or use of any motor vehicle registered in my/our name(s) in the Commonwealth of Virginia. I/we agree that any lawful process or notice to me/us which is served on the Commissioner shall have the same legal effect as if served on me/us within the Commonwealth of Virginia. POWER OF ATTORNEY INFORMATION