A BC D 1

STATE OF FLORIDA

DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES ¨C DIVISION OF MOTORIST SERVICES

SUBMIT THIS FORM TO YOUR LOCAL TAX COLLECTOR OR LICENSE PLATE AGENT OFFICE

locations/

APPLICATION FOR PERSONALIZED LICENSE PLATE

INSTRUCTIONS ARE INDICATED ON REVERSE SIDE

Date of Application

PLEASE CONTACT YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE, LICENSE PLATE AGENT

OR REFER TO THE REVERSE SIDE OF THIS FORM FOR FEE INFORMATION.

OWNER / APPLICANT IDENTIFICATION

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Owner¡¯s / Lessee¡¯s Name:

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Street Address:

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Owner¡¯s / Lessee¡¯s D/L Number:

City:

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Street Address:

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City:

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Sex:

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Date of Birth:

State:

Owner¡¯s / Lessee¡¯s E-mail Address:

Co-Owner¡¯s / Co-Lessee¡¯s Name:

Co-Owner¡¯s / Co-Lessee¡¯s D/L Number:

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Sex:

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Zip:

FEID#:

Date of Birth:

State:

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Co-Owner¡¯s / Co-Lessee¡¯s E-mail Address:

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Zip:

FEID#:

VEHICLE INFORMATION

Current Decal Number:

Current License Plate Number:

Title Number:

Vehicle Identification Number:

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Vehicle Make:

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Year:

Color:

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Vehicle Type:

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Vehicle Weight:

CERTIFICATION

This is to certify that I am/we are the registered owner/lessee or co-owner/co-lessee of the motor vehicle referenced above.

I/we authorize my/our name, address, and renewal date to be provided to the organization sponsoring the specialty license plate selected.

Under penalties of perjury, I/we declare that I/we have read the foregoing document and that the facts stated in it are true.

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Signature(s):

LICENSE PLATE SELECTION (see reverse side for plate choices)

Enter the type of license plate requested: (see reverse

side of this form for types of plates and fees)

Specify the intended meaning/explanation for your

personalized license plate configuration choice

(nickname, initials, etc.):

Please Note:

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Use no more than the number of characters authorized for the type of license plate you have requested

(including a space or hyphen, see reverse side).

For license plates with center graphic, allow two spaces for the logo or characters will cover the graphic design.

Centered Graphic

(7 characters, may also have an additional space or hyphen.

A regular motorcycle may have a Florida graphic.)

Left Graphic

Specialty Motorcycle

(5 characters)

(6 characters)

111AIBIC IDI1

LOGO

1ST CHOICE

2ND CHOICE

3RD CHOICE

4TH CHOICE

1.

2.

3.

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INSTRUCTIONS

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Carefully read all information on the front and back of this application before completing the application.

Complete the application form and submit it to your local county tax collector's office or license plate agent with the following items:

a.

PROOF OF FLORIDA INSURANCE: Proof of personal injury protection (PIP) and property damage liability insurance (PDL) must be submitted in the form

of a card, policy, binder, certificate of insurance or affidavit.

b.

A copy of your current registration certificate or renewal notice.

c.

Remittance fees (payable to your county tax collector/license plate agent).

Please allow six to eight weeks for the manufacture and delivery of the license plate. The license plate will be delivered to your county tax collector's office or

license plate agent.

HSMV 83043 (Rev. 02/24) S



IMPORTANT INFORM ATION ABOUT YOUR CHOICE

You may check personalized plate availability at the department¡¯s websitelocated at

Your local county tax collector's office or license plate agent may assist you in determining if a specific type of license plate is available, as well

as the choice for personalization and the total cost of the license plate you desire, including trucks (with a net weight of more than 5,000 pounds),

"for-hire" vehicles and trailers.

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Yourchoice mayincludeletters,numbers, aspaceor ahyphenascharacters.License plates thathave 7characters may havean

additionalspace or hyphen. However,license plates that have 5 characters, may NOT have an additionalspace or hyphen.

Requests with obscene or objectionable words will be rejected. If a personalized license plate has been issued and later determined to be

obscene or objectionable, the department will recall the license plate.

TYPE OF LICENSE PLATES

Personalized license plates for motorcycles are only available as a "Florida Graphic" or "Motorcycle Specialty" license plate.

TYPES OF LICENSE PLATES (See for more information)

AIR FORCE **

ARMY **

COAST GUARD **

INDIAN RIVER LAGOON **

MARINE CORPS **

NAVY **

OLYMPIC SPIRIT **

CHOOSE LIFE **

EVERGLADES RIVER OF GRASS **

POLICE ATHLETIC LEAGUE **

PROTECT WILD DOLPHINS **

SUPPORT EDUCATION **

SALUTES FIREFIGHTERS **

SUPPORT LAW ENFORCEMENT **

MAXIMUM

CHARACTER

SALUTES VETERANS **

SHARE THE ROAD **

TAMPA BAY ESTUARY **

5

$71.40

5

$76.40

5

$78.40

5

$81.40

FLORIDA STATE MOTTO *

6

7

STATE WILDFLOWER *

7

$73.40

$51.40

$71.40

7

$76.40

7

$81.40

7

$79.40

5

$81.40

5

$81.40

4

$81.40

6

$81.40

FISH FLORIDA**

A STATE OF VISION **

AGRICULTURE EDUCATION **

AMERICA THE BEAUTIFUL **

ANIMAL FRIEND **

BEST BUDDIES **

BIG BROTHERS BIG SISTERS **

BLUE ANGELS**

CHALLENGER/COLUMBIA **

CONSERVE WILDLIFE **

DISCOVER FLORIDA HORSES**

DISCOVER FLORIDA OCEANS **

DUCKS UNLIMITED **

END BREAST CANCER **

ENDLESS SUMMER**

EXPLORE OFF ROAD FLORIDA **

FALLEN LAW ENFORCEMENT

OFFICERS**

FLORIDA SHERRIFFS ASSOC **

FLORIDA SHERIFF'S YOUTH RANCHES **

FRATERNALORDER OF POLICE**

FREEMASONRY **

GADSDEN FLAG **

GO FISHING **

HORSE COUNTRY **

HOSPICE EVERYDAY IS A GIFT **

IN GOD WE TRUST **

KEEP KIDS DRUG FREE **

LAUREN¡¯S KIDS **

NASCAR **

PLAY TENNIS **

PROTECT FLORIDA WHALES **

PROTECT MARINE WILDLIFE **

PROTECT OUR OCEANS**

PROTECT OUR REEFS **

(***) SAVE OUR SEAS **

SAVE WILD FLORIDA**

STOP CHILD ABUSE **

SUPPORT AUTISM PROGRAMS **

SUPPORT HOMEOWNERSHIP FOR ALL**

SUPPORT OUR TROOPS **

TREES ARE COOL **

VISIT OUR LIGHTS **

WALT DISNEY WORLD**

WILDLIFE FOUNDATION OF FLORIDA **

MOTORCYCLE SPECIALTY **

FLORIDA GRAPHIC *

SPECIAL OLYMPICS FLORIDA *

AGRICULTURE *

INVEST IN CHILDREN *

SCOUTING TEACHES VALUES *

STATE OF THE ARTS *

(***)AQUACULTURE *

CONSERVE FLORIDA¡¯S FISHERIES *

DIVINE NINE *

EXPLORE STATE PARKS *

FAMILY FIRST *

FAMILY VALUES *

GOLF CAPITAL OF THE WORLD *

IMAGINE*

LIVE THE DREAM*

PROTECT THE PANTHER *

PROTECT FLORIDA SPRINGS*

SAVE THE MANATEE*

STOP HEART DISEASE*

UNITED WE STAND*

HELPING SEA TURTLES SURVIVE *

COLLEGIATE:

ADVENT HEALTH UNIVERSITY ICUF **

AVE MARIA UNIVERSITY ICUF **

BARRY UNIVERSITY **

BEACON COLLEGE ICUF **

BETHUNE-COOKMAN UNIVERSITY **

ECKERD COLLEGE ICUF **

EDWARD WATERS COLLEGE ICUF **

EMBRY-RIDDLE AERONAUTICAL U ICUF **

EVERGLADES UNIVERSITY ICUF **

FLAGLER COLLEGE ICUF **

FLORIDA A & M UNIVERSITY **

FLORIDA ATLANTIC UNIVERSITY **

FLORIDA COLLEGE ICUF **

FLORIDA PROFESSIONAL SPORTS

TEAM:

FLORIDA MARLINS **

JACKSONVILLE JAGUARS **

MIAMI DOLPHINS **

FLORIDA GULF COAST UNIVERSITY *

FLORIDA INSTITUTE OF TECHNOLOGY ICUF **

FLORIDA INTERNATIONAL UNIVERSITY **

FLORIDA MEMORIAL UNIVERSITY ICUF**

FLORIDA SOUTHERN COLLEGE ICUF **

FLORIDA STATE UNIVERSITY **

JACKSONVILLE UNIVERSITY ICUF **

KEISER UNIVERSITY ICUF **

LYNN UNIVERSITY ICUF **

NOVA SOUTHEASTERN U ICUF**

PALM BEACH ATLANTIC U ICUF**

RINGLING SCHOF ART & DESIGN ICUF **

MIAMI HEAT **

ORLANDO MAGIC **

TAMPA BAY BUCCANEERS **

ROLLINS COLLEGE ICUF **

SAINT LEO UNIVERSITY ICUF**

SAINT THOMAS UNIVERSITY ICUF **

SOUTHEASTERN UNIVERSITY ICUF **

STETSON UNIVERSITY ICUF **

UNIVERSITY OF CENTRAL FLORIDA **

UNIVERSITY OF FLORIDA **

UNIVERSITY OF GEORGIA **

*UNIVERSITY OF MIAMI **

UNIVERSITY OF SOUTH FLORIDA **

UNIVERSITY OF TAMPA ICUF**

UNIVERSITY OF WEST FLORIDA **

WARNER SOUTHERN COLL ICUF **

WEBBER INTERNATIONAL U ICUF **

TAMPA BAY LIGHTNING **

TAMPA BAY RAYS**

BLUE ANGLES MOTORCYCLE **

ORLANDO CITY SOCCER *

FLORIDA PANTHERS *

Amount Includes All Fees (SEE "FEE EXCEPTIONS" BELOW).

*Graphic design is centered on the plate

**Graphic design is on the far left/right side of the plate.

***If applying for more than 10 license plates for the same owner the fee is $67.55 per license plate.

FEE EXCEPTIONS: An additional branch fee of $.50 may be required by some county agencies.

An additional license plate mail fee of $5.45 is required if a license plate is mailed to the applicant.

The annual or biennial registration fee is due in addition to these fees shown.

Visitthefollowingwebsitefor current mailingaddresses:

HSMV 83043 (Rev. 2/24) S

FEES



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