DMV-42-NSCR REV 9/18 Application for a License Plate Department of Transportation Division of Motor Vehicles Special Plates PO Box 17120 Charleston, WV 25317 Name(s) of Registered Owner(s)* ______Address of Registered Owner(s) ______City ______Zip ______Phone (_____)______Vehicle Make ______Vehicle Year ______Title No. ______Serial No. ______Current License Plate ______

From ______To ______Policy ______Insurance Company ______Insurance Agent ______NAIC ______

*The name of owner(s) which you wish to register the license plate under should appear as shown on the current registration card. Current Plates Include: Check the box next to the license plate you wish to purchase.

Standard NASCAR #3 #14 Commemorative

#17

#29 #48 #88 Dale Earnhardt Jr. #99

Please check with the DMV for available team designs: 1-800-642-9066 • www.dmv.wv.gov • or visit your reg ce. Plate pricing is listed on the back.

Applicant’s Statement FOR DMV USE ONLY This application is being returned for the following reasons: The information above is true and correct to the best of my knowledge and belief, and I understand that any false statements may result in legal Selection is taken. Please make a new selection. penalties pursuant to West Virginia Law §17A-9-1: Fraudulent Applications. Incorrect payment included. Correct amount $ ______No payment included. Correct amount $ ______No record of vehicle. Please provide a current copy ______of title or registration. SIGNATURE OF APPLICANT DATE Other______

*If you would like to personalize your Plate, please complete the section on the back. Personalized Plate Detail

Six positions are allowed. Provide a minimum of two and maximum of six characters per choice. Each choice must include at least one alpha character. Symbols and punctuation marks cannot be used.

Place characters in boxes exactly as you want them to appear on the plate. All characters will be centered in relation to the driver logo on the plate, unless you clearly specify otherwise. PLEASE PRINT CLEARLY.

1st Choice 2nd Choice 3rd Choice 4th Choice

Fees For Plates Listed Below

Plate Standard Personalized October 1st $86.50 $101.50 November 1st $82.33 $99.12 December 1st $78.17 $96.74 January 1st $74.00 $94.36 February 1st $69.83 $91.98 March 1st $65.67 $89.60 April 1st $61.50 $87.22 May 1st $57.33 $84.84 June 1st $53.17 $82.46 July 1st $49.00 $80.08 August 1st $44.83 $77.70 September 1st $86.50 $75.32 Renewal Fee $76.50 $91.50

Please check with the DMV for available team designs: 1-800-642-9066 • www.dmv.wv.gov • or visit your reg ce.