Form MVR-17 "Emergency Medical Services Plates Application" - Maine

What Is Form MVR-17?

This is a legal form that was released by the Maine Department of the Secretary of State - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2017;
  • The latest edition provided by the Maine Department of the Secretary of State;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MVR-17 by clicking the link below or browse more documents and templates provided by the Maine Department of the Secretary of State.

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Download Form MVR-17 "Emergency Medical Services Plates Application" - Maine

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Department of the Secretary of State
BMV Use Only
Maine Bureau of Motor Vehicles
Excise Tax Receipt
#:________________________
EMERGENCY MEDICAL SERVICES
Plate #:___________________
PLATES APPLICATION
Date Issued: __________________
Issued By:
___________________
I, ___________________________________________________________________________________
(NAME OF APPLICANT)
of __________________________________________________________________________________,
(STREET)
(TOWN)
(ZIP CODE)
hereby make application for an Emergency Medical Services plate and enclosed is the one-time $5.00
plate fee and a copy of my current registration to which the plate will be assigned.
EMS License Number: ____________________________
EMS License Expiration Date: ______________________
Check here if a vanity plate is desired: The fee for a vanity plate is $25.00; the fee for EMS plates
is a one-time $5.00 fee. Please submit this application along with a Vanity Plate Application (MV-45), a
copy of your current registration, and the appropriate fee. Please make checks payable to Secretary of
State.
I fully understand should I cease to be a licensed emergency medical services person, I shall immediately
notify the Secretary of State and understand the plate must be returned to the Secretary of State. If I retire
from Emergency Medical Services, I am able to retain the plate as a memento but cannot display the plate
on my vehicle.
NOTE: The vehicle to which the EMS plate will be assigned must be registered in the name of the active
EMS licensee. The special registration plate for EMS licensees may be used only on one motor vehicle.
The registered vehicle weight of this vehicle may not exceed 10,000 pounds. (29-A MRSA §519-A)
____________________________________________
___________________________
(SIGNATURE OF APPLICANT)
(Date)
Please submit the completed application, copy of your current registration, and payment to:
Specialty Plate Clerk
Bureau of Motor Vehicles
29 State House Station
Augusta, ME 04333-0029
101 Hospital Street, 29 State House Station, Augusta, ME 04333-0029
Phone: (207) 624-9000 Ext. 52149 TTY users call Maine relay 411
MVR-17 Rev. 12/17
Department of the Secretary of State
BMV Use Only
Maine Bureau of Motor Vehicles
Excise Tax Receipt
#:________________________
EMERGENCY MEDICAL SERVICES
Plate #:___________________
PLATES APPLICATION
Date Issued: __________________
Issued By:
___________________
I, ___________________________________________________________________________________
(NAME OF APPLICANT)
of __________________________________________________________________________________,
(STREET)
(TOWN)
(ZIP CODE)
hereby make application for an Emergency Medical Services plate and enclosed is the one-time $5.00
plate fee and a copy of my current registration to which the plate will be assigned.
EMS License Number: ____________________________
EMS License Expiration Date: ______________________
Check here if a vanity plate is desired: The fee for a vanity plate is $25.00; the fee for EMS plates
is a one-time $5.00 fee. Please submit this application along with a Vanity Plate Application (MV-45), a
copy of your current registration, and the appropriate fee. Please make checks payable to Secretary of
State.
I fully understand should I cease to be a licensed emergency medical services person, I shall immediately
notify the Secretary of State and understand the plate must be returned to the Secretary of State. If I retire
from Emergency Medical Services, I am able to retain the plate as a memento but cannot display the plate
on my vehicle.
NOTE: The vehicle to which the EMS plate will be assigned must be registered in the name of the active
EMS licensee. The special registration plate for EMS licensees may be used only on one motor vehicle.
The registered vehicle weight of this vehicle may not exceed 10,000 pounds. (29-A MRSA §519-A)
____________________________________________
___________________________
(SIGNATURE OF APPLICANT)
(Date)
Please submit the completed application, copy of your current registration, and payment to:
Specialty Plate Clerk
Bureau of Motor Vehicles
29 State House Station
Augusta, ME 04333-0029
101 Hospital Street, 29 State House Station, Augusta, ME 04333-0029
Phone: (207) 624-9000 Ext. 52149 TTY users call Maine relay 411
MVR-17 Rev. 12/17