OPTIONAL PERSONALIZATION REQUEST

Daytime Telephone Number

Home: ______________________

Office: ______________________

A LIST INFORMATION AS SHOWN ON YOUR DEALER AUTHORIZATION CARD

B

Dealer Registration Plate Number Being Replaced Expiration Date

The number of allotted letters or numbers in combination varies depending on the selected registration plate type. Pre-printed letter configurationsor designated letter(s) appear on personalized registration plates based on the type of registration plate requested. Please see the reverseside 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.

FIRST CHOICE SECOND CHOICE THIRD CHOICE

C APPLICANT(S) SIGNATURE

I/We certify that I/we meet all eligibility requirements to have the special registration plate as indicated above issued to me. In addition, my signaturebelow hereby certifies under penalty of law that the information contained herein is TRUE and CORRECT. WARNING: Falsification to authorities is amisdemeanor 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]).

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: ________.

MV-904D (7-19)

APPLICATION FOR PERSONALIZEDDEALER REGISTRATION PLATES For Department Use OnlyBureau of Motor Vehicles • PO Box 68283 • Harrisburg, PA 17106-8293

Co-Owner Last Name First Name Middle Name PA DL/Photo ID# Date of Birth

Last Name (or Full Business Name) First Name Middle Name PA DL/Photo ID#or Bus. ID#

Date of Birth

Street Address

City State Zip Code

CHECK BLOCK FOR TYPE OF REGISTRATION PLATE DESIRED:

q Personalized Standard Dealer Registration Plate (11) q Personalized Farm Equipment Dealer Registration Plate (37) q Personalized Multipurpose Dealer Registration Plate (F1) q Personalized Repair/Towing Dealer Registration Plate (D1) q Personalized Repossessor/Financier Dealer Registration Plate (D4)q Personalized Salvor Yard Dealer Registration Plate (D2)

Dealer/Business Partner Identification Number(Required to order personalizeddealer registration plates.)

Signature of Owner or Authorized Signer Signature of Co-Owner Date

FEE: $108

q Personalized Transporter Dealer Registration Plate (D3) q Personalized Moped Dealer Registration Plate (J7) q Personalized Motorcycle Dealer Registration Plate (J6) q Personalized Trailer Dealer Registration Plate (I6)q Personalized Watercraft Trailer Dealer Registration Plate (H6)

NOTE: If applying for registration in addition to personalization of your dealer registration plate, the appropriate registration fee and form must becompleted and attached to this application to apply for the dealer registration plate.

www.dmv.pa.gov

NOTE: When requesting a numeric character of zero, please show as "Ø" instead of the alpha character "O." Since this is an electronically fillableform, after printing the form, please be sure any zero is marked with a "/."

IF PERSONALIZING YOUR REGISTRATION PLATE

• Personalized Dealer registration plates may contain:

For Dealer registration plates, up to SEVEN letters or numbers in combination. NOTE: One hyphen or space is permitted (but not both) in addition to the SEVEN available spaces for personalization. If no hyphen or space isrequested, one block will remain blank. No additional special characters are available.

For Farm Equipment Dealer registration plates, up to FOUR letters or numbers 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. Whenrequesting a numeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printedletter configuration of “FE” will precede your personalized configuration and a "D" will follow your personalizationconfiguration on your registration plate and cannot be changed.

For Multipurpose Dealer registration plates, up to FOUR letters or numbers 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. Onlyone hyphen or space is permitted, but not both. No additional special characters are available. When requesting a numeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letter configuration of “MP” will precede your personalized configuration and a "D" will follow your personalizationconfiguration on your registration plate and cannot be changed.

For Repair/Towing Dealer registration plates, up to FIVE letters or numbers in combination. If a hyphen or spaceis used as part of the registration configuration, it counts as one of the available spaces for personalization. Onlyone hyphen or space is permitted, but not both. No additional special characters are available. When requestinga numeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letterconfiguration of “RT” will precede your personalized configuration on your registration plate and cannot bechanged.

For Repossessor/Financier Dealer registration plates, up to FIVE letters or numbers 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.When requesting a numeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letter configuration of “RE” will precede your personalized configuration on your registration plate andcannot be changed.

For Salvor Yard Dealer registration plates, up to FIVE letters or numbers in combination. If a hyphen or space isused as part of the registration configuration, it counts as one of the available spaces for personalization. Only onehyphen or space is permitted, but not both. No additional special characters are available. When requesting anumeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letterconfiguration of “WL” will precede your personalized configuration on your registration plate and cannot bechanged.SAM

PLE

For Transporter Dealer registration plates, up to FIVE letters or numbers in combination. If a hyphen or space isused as part of the registration configuration, it counts as one of the available spaces for personalization. Only onehyphen or space is permitted, but not both. No additional special characters are available. When requesting anumeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letter configuration of “DT” will precede your personalized configuration on your registration plate and cannot bechanged.SAM

PLE

For Moped Dealer registration plates, up to FOUR letters or numbers in combination. If a hyphen or space is usedas part of the registration configuration, it counts as one of the available spaces for personalization. Only onehyphen or space is permitted, but not both. No additional special characters are available. When requesting anumeric character of zero, please list as "Ø" instead of the alpha character of "O".

SAMPLE

For Motorcycle Dealer registration plates, up to FOUR letters or numbers in combination. If a hyphen or space isused as part of the registration configuration, it counts as one of the available spaces for personalization. Only onehyphen or space is permitted, but not both. No additional special characters are available. When requesting anumeric character of zero, please list as "Ø" instead of the alpha character of "O".

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

• The Keystone logo does not appear on personalized registration plates.

• 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 "/."

• PennDOT reserves the right to limit or reject requests.

• The fee to personalize your dealer registration plates is $108. Your dealer registration plate must be current in order forPennDOT to process your request. The $108 fee covers the cost of your personalized registration plate order onlyand will not renew your vehicle's registration.

• To check personalized registration plate availability, visit PennDOT’s Driver and Vehicle Services website,www.dmv.pa.gov, and select Plate Availability from the list of services under the Online Services heading. Personalizedregistration plates will not be reserved until PennDOT receives payment and a completed application, and approves yourrequested registration plate configuration [number(s) and/or letter(s)]. Please note that registration plate requests areprocessed on a first-come, first-served basis. Although a requested registration plate configuration may show as beingavailable on the website, it is possible that a request for the same registration plate configuration may have already beensubmitted by another customer and may not be available when making application.

• Personalized registration plates will be manufactured on the basis of this application. NO REFUND of the fee will beissued when an applicant cancels a request after the order is placed with the manufacturer.

• Allow eight to 10 weeks for delivery.

For Trailer Dealer registration plates, up to FOUR letters or numbers in combination. If a hyphen or space is usedas part of the registration configuration, it counts as one of the available spaces for personalization. Only onehyphen or space is permitted, but not both. No additional special characters are available. When requesting anumeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letterconfiguration of “TD” will precede your personalized configuration and a "D" will follow your personalization configuration on your registration plate and cannot be changed.SAM

PLE

For Watercraft Trailer Dealer registration plates, up to FIVE letters or numbers in combination. If a hyphen orspace 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. When requesting a numeric character of zero, please list as "Ø" instead of the alpha character of "O". NOTE: A pre-printed letter configuration of “WD” will precede your personalized configuration on your registration plate and cannot bechanged.SAM

PLE

Visit us at www.dmv.pa.gov or call us at 717-412-5300. TTY callers — please dial 711 to reach us.

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