State of Delaware
Department of Public Safety
Division of Motor Vehicles
P. O. Box 698     Dover, Delaware 19903

(Type or Print)

DATE OF APPLICATION ____________________________________

ORGANIZATION'S NAME ___________________________________________________________________

REGISTRATION NUMBER _______________________       MFG. AND YEAR ___________________________

VEHICLE IDENTIFICATION # ______________________________________

NAME ___________________________       TELEPHONE NUMBER ______________________________

ADDRESS _______________________       SIGNATURE OF APPLICANT ___________________________



I understand the special plate is to be displayed only on the vehicle described above. (If you trade vehicles, your registration showing this plate must be presented to the Division of Motor Vehicles so a new card can be issues.)

The fee of $10.00 must accompany this application. This is a one-time charge only. However, you must still continue to have your vehicle inspected and pay your inspection fee. (As required.)

Only one (1) plate will be issued to an applicant. Upon receipt of notice that the individual is no longer affiliated with the organization for which the specialty plate has been issued, the plate must be returned to the Division of Motor Vehicles within 90 days per Title 21, Section 2139B.

Plates may be issued only on cars, station wagons, or trucks with no more than three-fourths ton maximum gross weight (10,000 gross vehicle weight).

I can be reached during the day at: Telephone No. ______________________

Verifying Appointee

Form M-613