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Application for Special Fund Registration Plate MV-911 (7-21) www.dmv.pa.gov APPLICATION FOR SPECIAL FUND For Department Use Only REGISTRATION PLATE Bureau of Motor Vehicles • P.O. Box 67900 • Harrisburg, PA 17106-7900 PLEASE CHECK (3) TYPE OF REGISTRATION PLATE REQUESTED - See reverse side for picture of registration plate and additional information. r Wild Resource Conservation Fund (IY) - Fee: $38 ($15 from the fee goes toward the designated fund and an additional $112 is required for personalization.) r Pennsylvania Zoological Council Fund (HR) - Fee: $57 ($23 from the fee goes toward the designated fund and an additional $112 is required for personalization.) r Preserve Our Heritage (L6) - Fee: $57 ($23 from the fee goes toward the designated fund.) NOTE: This full color registration plate is not available for personalization. r Pennsylvania Monuments (IM) - Fee: $57 ($23 from the fee goes toward the designated fund and an additional $112 is required for personalization.) Check One: Leased Vehicle: r Yes r No NOTE: If the vehicle is a leased vehicle, Form MV-1L, “Application for Lessee Information,” must be completed and attached. Form MV-1L is available on our website at www.dmv.pa.gov. A VEHICLE DESCRIPTION AND APPLICANT INFORMATION - Complete this section exactly as information appears on current registration card. Title Number Vehicle Identification Number Registration Plate Number Expiration Date Make of Vehicle Year Last Name (Or Full Business Name) First Name Middle Name PA DL/Photo ID# Date of Birth or Bus. ID# Co-Owner Last Name First Name Middle Name PA DL/Photo ID# Date of Birth Street Address City State Zip Code Telephone Number: Home: ( ) _____________________ Work:: ( ) _____________________ NOTE: In conjunction with replacement of your registration plate, you will receive one registration card. If additional registration cards are desired, the fee is $2 for each registration card. Number of duplicate registration cards requested @ $2 each: _________. B OPTIONAL PERSONALIZATION REQUEST - NOTE: Additional $112 fee required. Personalized Special Fund registration plate choices may contain up to FIVE letters or numbers in combination. Pre-printed letter configurations or designated letter(s) appear on personalized registration plates based on the type of registration plate requested. Please see the reverse side of this application for additional information. Only one hyphen or space is permitted as part of the available spaces for personalization. No other special characters are available. Please use capital letters and print clearly. NOTE: The full color Preserve Our Heritage registration plate is not available for personalization. FIRST CHOICE SECOND CHOICE THIRD CHOICE NOTE: When requesting a numeric character of zero, please show as "Ø" instead of the alpha character "O." Since this is an electronically fillable form, after printing the form, please be sure any zero is marked with a "/." C APPLICANT SIGNATURE I/We hereby certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I/we understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]). Signature of Applicant Date Signature of Co-Applicant Date Request the Following Special Registration Plate (Please Check Type of Registration Plate Requested on Front Side of Form) Wild Resource Conservation Fund (WRCF) Benefits the Management and Conservation of the Commonwealth’s Flora and Fauna. You can own a vehicle registration plate that helps support the management of our wild resources to include protecting PA wildlife (which describes all forms of wildlife that are not pursued by hunters, furtakers or anglers). The number of birds, animals, fish, reptiles, and amphibians in this protected wildlife category represents 80 percent of all wildlife in PA. The Wild Resource Conservation Board has the responsibility of selecting studies and projects recommended by the state’s resource agencies, Department of Conservation and Natural Resources, PA Fish and Boat Commission, and PA Game SAMPLE Commission. Through generous donations, the Wild Resource Conservation Board has been able to fund many projects including reestablishing the River Otter, reintroducing the osprey, and generating a computer database of endangered and Plate Colors - Blue, white and yellow threatened species in PA. WRCF is funded entirely by donated funds from the state tax check-off, direct contributions, and from the sale of this registration plate. For Personalized Wild Resource Conservation Fund (WRCF) registration plates, up to FIVE letters and/or numbers may be used in combination. If a hyphen or space is used as part of the registration configuration, it counts as one of the available spaces for personalization. Only one hyphen or space is permitted, but not both. No additional special characters are available. Please use capital letters and print clearly. When requesting a numeric character of zero, please show as "Ø" instead of the alpha character "O." Since this is an electronically fillable form, after printing the form, please be sure any zero is marked with a "/." A pre-printed letter configuration of “RC” will precede your personalized configuration on your registration plate and cannot be changed. Preserve Our Heritage Benefits the educational and exhibit programs of the Pennsylvania Historical and Museum Commission. You can have your very own registration plate commemorating Pennsylvania's proud railroading heritage. Whether you love trains, appreciate fine art, or like a unique registration plate, you’ll want this distinctive PennDOT registration plate that features Grif Teller’s famous 1928 painting When the Broadway Meets the Dawn. The painting depicts the Pennsylvania Railroad’s Broadway Limited on its Chicago to New York run as the first light of day breaks along the Juniata River in central Pennsylvania. The registration plate reproduces the rich, deep colors of Teller’s original work of art, capturing the power and speed of the onrushing locomotive. The Pennsylvania Railroad played a key role in making the commonwealth a leader in the railroading industry. The “Pennsy” story comes alive at the world-class Railroad Museum of Pennsylvania in Strasburg, Lancaster County, and in the collections of the State Archives of Pennsylvania in Harrisburg. Your support Plate Colors - Brown, orange, red and white will help underwrite the educational and exhibit programs of the Pennsylvania Historical and Museum Commission. This registration plate is not available for personalization at this time. Pennsylvania Zoological Council Fund Benefits the Philadelphia Zoo, the Pittsburgh Zoo, the Erie Zoo, the National Aviary in Pittsburgh, the Elmwood Park Zoo in Norristown and the Lehigh Valley Zoo. You can own a vehicle registration plate that helps save endangered wildlife and lets you show your support for zoos wherever you drive. Created by the Zoological Council, this registration plate pictures one of the most magnificent and endangered animals in the world - the Siberian Tiger. The Pennsylvania Zoological Council is comprised of six institutions: The Philadelphia Zoo; the Pittsburgh Zoo; the Erie Zoo; the National Aviary in Pittsburgh; the Elmwood Park Zoo in Norristown; and the Lehigh Valley Zoo. Each institution is devoted to animal conservation and education programs. Proceeds from the sale of the registration plates will directly support these groups and their important projects, which include SAMPLE captive breeding of endangered species; creating bird sanctuaries on recovered wetlands; providing community education programs; constructing exciting interactive exhibits, and reintroducing endangered species into the wild. Purchase the zoo Plate Colors - Blue, white and yellow registration plate, and you immediately add your support to the efforts of the Pennsylvania Zoological Council. You’ll also show others your love for wild animals. For Personalized Pennsylvania Zoological Council Fund registration plates, up to FIVE letters and/or numbers may be used in combination. If a hyphen or space is used as part of the registration configuration, it counts as one of the available spaces for personalization. Only one hyphen or space is permitted, but not both. No additional special characters are available. Please use capital letters and print clearly. When requesting a numeric character of zero, please show as "Ø" instead of the alpha character "O." Since this is an electronically fillable form, after printing the form, please be sure any zero is marked with a "/." A pre-printed letter configuration of “PZ” will follow your personalized configuration on your registration plate and cannot be changed. Pennsylvania Monuments Benefits the Veterans Trust Fund. Purchase the Pennsylvania Monuments registration plate and show your support for the cleaning, repair and restoration of Pennsylvania monuments. The registration plate pictures the Pennsylvania Memorial Monument found at the Gettysburg National Military Park and displays the words “Gettysburg 1863.” Proceeds from the sale of this registration plate go directly to the Veteran Trust Fund and will be used exclusively to provide grants to nonprofit organizations for the cleaning, repair and restoration of Pennsylvania Monuments by the Gettysburg National Military Park. SAMPLE For Personalized Pennsylvania Monuments registration plates, up to FIVE letters and/or numbers may be used in Plate Colors - Blue, white and yellow combination. If
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