KENTUCKY TRANSPORTATION CABINET
Department of Vehicle Regulation
DIVISION OF MOTOR VEHICLE LICENSING / TC 96-15
Rev. 10/2016
Page 1 of 1
APPLICATION FOR SPECIAL LICENSE PLATE
INSTRUCTIONS/INFORMATION
Individual applicants must submit this application to the contact person for the non-profit organization. Each application must be accompanied with a $25 payment. Checks are to be made payable to the group or organization.
NOTE: THE ORIGINAL APPLICATION IS TO BE RETAINED BY THE ORGANIZATION AS PROOF OF LICENSE PLATE PURCHASE. THE APPLICANT RECEIVES A COPY.
SECTION 1: APPLICANT INFORMATION
Pursuant to Kentucky Revised Statute (KRS) 186.164, I am making application for the following special license plate:
PLATE NAME
APPLICANT NAME
ADDRESS
CITY
/ COUNTY (residence)
/ STATE
/ ZIP
/ PHONE (daytime, include area code)