APPLICATION FOR EMBOSSED PLATES

APPLICANT AND VEHICLE INFORMATION PLEASE NOTE – THIS APPLICATION IS TO ORDER EMBOSSED PLATES FOR PLATE COMBINATIONS THAT YOU ALREADY OWN AND HAVE IN YOUR POSSESSION. IF YOU ARE ORDERING A NEW SPECIALTY PLATE THAT YOU WOULD LIKE TO HAVE EMBOSSED, USE THE APPLICATION FORM FOR THAT PLATE TYPE AND CHECK THE OPTION ON THAT APPLICATION FOR EMBOSSED PLATES. ALLOW 10-12 WEEKS FOR EMBOSSED PROCESSING. Applicant Name (Must be an owner or lessee on the vehicle title)

Mailing Address City State ZIP

Daytime Phone Number Email Address ( ) -

STEP STEP #1 Vehicle Make Year Model

County Where Vehicle is Registered

VEHICLE TYPE (Check one vehicle type only) Passenger/SUV (P) Truck (T) Motorcycle (M) House Trailer (H) Motor Home (P) Trailer (X) Light Trailer (L) MPV (V) Handicap (W) Handicap Motorcycle Commercial (C) Commercial Trailer (U) Apportioned Apportioned Trailer CURRENT PLATE INFORMATION CAUTION - THIS SECTION MUST BE FILLED OUT CORRECTLY - NO REFUND WILL BE GIVEN IF APPLICANT PROVIDES INCORRECT INFORMATION. County Number on Plate (if applicable) Current License Plate Number

Number(s) BEFORE the horse or dot on plate Number(s) AFTER the horse, emblem or dot on plate PLATE TYPE (Check ONE plate type only) $50.00 FEE PAYABLE TO WYDOT COUNTY PLATE OTHER SPECIALTY Standard Prestige VETERAN MILITARY Radio Amateur

STEP STEP #2 Air Force Disabled Vet Firefighter Army Former P.O.W. EMT Marine Corps Pearl Harbor University of Wyoming Navy Purple Heart Pioneer Coast Guard National Guard Street Rod Merchant Marines Retired National Guard Custom Vehicle Other:______IMPORTANT: THESE PLATES MAY TAKE 10-12 WEEKS FOR PROCESSING. THE FEE FOR EMBOSSED LICENSE PLATES IS $50.00 MADE PAYABLE TO WYDOT. A COPY OF YOUR REGISTRATION AND THE $50.00 MUST ACCOMPANY THIS APPLICATION OR IT WILL BE RETURNED. YOUR PLATE WILL BE DELIVERED TO THE COUNTY TREASURER'S OFFICE IN WHICH YOU ARE REGISTERED.

AFFIDAVIT 3 I hereby swear or affirm under penalty of perjury that all information on this application is true and correct.

Signature of Applicant Date STEP STEP #

APPLICANT SHALL MAIL APPLICATION, COPY OF THE VEHICLE REGISTRATION, AND FEE PAYABLE TO WYDOT: 4 WYDOT, ATTN: Motor Vehicle Services, 5300 Bishop Blvd., Cheyenne, Wyoming 82009-3340 FOR ADDITIONAL INFORMATION PLEASE CALL: 307-777-4709 STEP STEP # or visit our website at http://www.dot.state.wy.us FOR WYOMING DEPARTMENT OF TRANSPORTATION USE ONLY Plate # Issued By Date

MV-145 (10/16)