Georgia Department of Revenue Georgia Department of Revenue by zqa20601


									                                        Georgia Department of Revenue
                                              Motor Vehicle Division
                                 Application for a Special Interest License Plate
  Submit this application to your county tag office with the $25 manufacturing fee per license plate. A separate application is
                                                 required for each license plate.
          This application must be typed, legibly printed by hand or electronically completed and printed and signed.
Applicant’s Full Legal Name:

Applicant’s Residence Address Including City, State & Zip Code:                                     County of Residence:

Daytime Telephone Number Including Area Code:                      Applicant’s Driver’s License Number:

Check the box indicating the type of license plate requested:

    □    African American History & Tourism in Georgia                 □    ‘In God We Trust’ – Boy Scouts of America
    □    AIDS Survival Project                                         □    Licensed Georgia Physician
    □    ALS, a/k/a/ ‘Lou Gehrig’s Disease’, Association of GA         □    Maritime History of Georgia’s Coast
    □    Alzheimer’s Association                                       □    NASCAR Officially Licensed Registration Plate
    □    Atlanta Braves Foundation                                     □    NASCAR Officially Licensed Registration Plate
    □    Atlanta Falcons Foundation                                         for Driver/Car/Team:_______________________
    □    Automobile Racing Hall Fame                                   □    National Rifle Association
    □    Beautification Projects in Cobb County                        □    100 Years of Scouting in the U.S.
    □    Beautification Projects in Georgia                            □    Pediatric Cancer Research – Joanna McAfee Child
    □    Benevolent & Protective Order of Elks                              Cancer Foundation
    □    BlazeSports Georgia (U.S. Disabled Athletes Fund)             □    Pediatric Cancer Treatment
    □    Bobwhite Quail                                                □    Persons With Diabetes
    □    Brain-Related Disorders                                       □    Project Lifesaver
    □    Breast Cancer Awareness                                       □    Promote Child Care Industry
    □    Bronze Star                                                   □    Promoting Arts in Georgia
    □    Child Abuse Prevention                                        □    Promoting Bicycle Safety
    □    Children’s Healthcare of Atlanta                              □    Rotary International
    □    Choose Life                                                   □    School Health & Physical Education Programs
    □    Civil War Battlefields & Historic Site Commemorative          □    Shrine Hospitals for Children
    □    Dog & Cat Sterilization                                       □    Sons of Confederate Veterans
    □    Dog & Cat Sterilization, Labrador Retriever – ‘Buddy’         □    Square & Round Dancers
    □    Family Member Serving in the Military                         □    Stroke Awareness
    □    Garden Club of Georgia, The                                   □    Support Cobb County Schools
    □    Georgia Center for the Book                                   □    Support Georgia Troops
    □    Georgia Equine Industry                                       □    Supporting Agriculture in Georgia
    □    Georgia Junior Golf Foundation                                □    Supporting Foster Parents
    □    Georgia War Veterans Nursing Home                             □    Supporting Public Schools
    □    Global War on Terrorism & Enduring Freedom                    □    Support Our Troops
    □    Global War on Terrorism & Iraqi Freedom                       □    Thanks Mom & Dad
    □    Historic Preservation Efforts in Georgia                      □    Treatment of Autism
    □    Honor Bronze Star Recipients                                  □    Trout Unlimited
    □    Honor Educators                                               □    Wildflower
    □    Honoring All Veterans                                         □    Wildlife – Eagle & U.S. Flag
    □    Honoring Georgia Association of Realtors                      □    Wildlife - Hummingbird
    □    Honoring Georgia Municipal Clerks
Applicant’s Signature:                                                                      Date:

Submit this application to your county tag office with the $25 manufacturing fee per license plate. A separate
application is required for each license plate. An annual special tag fee of $25 may be due at the time of registration,
as well as the usual registration fees and ad valorem taxes.

Please retain your receipt. When the manufacturing requirements have been met (1,000 ‘paid’ requests), you will
need this receipt to register your vehicle with this license plate.

Your license plates will be issued at the time 1,000 ‘paid’ applications are received for the plates you have
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