APPLICATION TO REQUEST A SPECIAL LICENSE PLATE FOR A FRATERNITY OR SORORITY

Under Title 27, Chapter 24, Subchapter 12 of the Arkansas Code, this application may be completed by a fraternity or sorority sponsoring a special license plate. The fraternity or sorority may request to establish a fund raising fee not to exceed $25.00.

The fraternity or sorority sponsoring a special license plate must remit twenty thousand dollars ($20,000), and provide five hundred (500) signatures of applicants who will register a vehicle with their special license plate. Fees and/or signatures will be due upon notification by the department of approval of license plate design. DO NOT SEND FEES WITH THIS APPLICATION.

Name and Address of Fraternity or Sorority

Fund raising fee to be established: Yes No

If a fund raising fee is to be established, enter amount not to exceed $25.00. Amount

Disposition of the design use contribution fees shall be in accordance with Arkansas Code 27-24-1207. See the reverse side of this form.

NAME AND ADDRESS OF PERSON TO CONTACT BY DEPARTMENT IF NEEDED PHONE NUMBER

E-MAIL ADDRESS IF ANY

Signature of person authorized to request plate for fraternity or sorority Date

This application may be submitted to either of the following addresses:

In Person: Office of Motor Vehicle By Mail: Department of Finance and Administration Ragland Building, Room 2041 Office of Motor Vehicle, Room 2041 1900 West 7th Street P.O. Box 1272 Little Rock, AR 72201 Little Rock, AR 72203

See back of form for additional information. Distribution of design use contribution fees:

27-24-1207. Disposition of fee — List.

(a) Except for African-American fraternities and sororities, the Revenue Division of the Department of Finance and Administration shall remit the design-use contribution fee required under 27- 24-1206(b)(2) monthly to the endowment funds of the participating institutions of higher education in the State of Arkansas that have a chapter of the fraternity or sorority on their campus on a pro-rata basis to be used for scholarships as provided in this subchapter.

(b)(1) The division shall remit the design-use contribution fee collected for special license plates issued to African-American fraternities and sororities monthly as provided under subdivision (b)(2) of this section to the endowment funds of the following historically black institutions of higher education in the State of Arkansas:

(A) The University of Arkansas at Pine Bluff; (B) Philander Smith College; (C) Arkansas Baptist College; and (D) Shorter College.

(2) The historically black institutions of higher education shall share in the funds in the following proportion:

(A) The University of Arkansas at Pine Bluff, forty percent (40%); (B) Philander Smith College, twenty-five percent (25%); (C) Arkansas Baptist College, twenty percent (20%); and (D) Shorter College, fifteen percent (15%).

(c) The department shall also provide to each participating African-American fraternity or sorority a list of persons who have paid for the special African-American fraternity or sorority license plates during the specified period.