Safety/Service Organization Special License Plate Application
120 State Street
DEPARTMENT OF MOTOR VEHICLES
Montpelier, Vermont 05603-0001
Agency of Transportation
(voice) 802.828.2000
Toll Free: 888-99-VERMONT
dmv.vermont.gov
TTD: 711
Last Name
First Name
Middle Initial
License #
Mailing Address
City
State
ZIP Code
Email
Phone
Current Plate No.
Model Year
Make
A one-time Safety/Service Organization
plate fee of $17.00 required.
Serial Number (VIN)
Professional Fire Fighters of Vermont
21
(Letter on company letterhead stating they are a member in good standing)
American Legion
38
(Copy of a valid membership ID card or letter of authorization from Post Adjutant)
Vermont State Firefighters Association Plate
40
(Authorization letter from V.S.F.A.)
Vermont National Guard Plate
41
(Authorization from Office of the Adjutant General, State of VT)
Vermont Amateur Radio Operator Plate
(Copy of Federal Communication Commission License)
42
FCC Call Sign:
VT Emergency Medical Services Plate [EMS]
46
(Authorization letter from VT Ambulance Association)
Vietnam Veterans of America
50
(Copy of a valid VT Membership card or signed authorization)
Lion’s Club
51
(Copy of membership ID card or letter of authorization from chapter officer)
Veterans of Foreign Wars
52
(Copy of valid membership card or an authorization signed by VFW Quartermaster)
Rotary International
53
(Copy of membership ID card or letter of authorization from chapter officer)
Grand Lodge of Vermont for Free Masons
54
(Copy of a valid membership ID card or letter of authorization from lodge secretary)
National Ski Patrol
68
(Copy of an active National Ski Patrol card)
STATEMENTS AND WARRANT MADE HEREIN ARE CERTIFIED UNDER PENALTY OF 23 V.S.A. § 202 & 203
Date
Signature of Applicant
DO NOT WRITE - DMV USE ONLY
 455
 465
 490 P
R
Veh. Type =
Reg Type =
92
Plate Type =
New Plate
 231  232
Date Issued:
Exp. Date
01
Special Plate
Old Plate No.
10
Miscellaneous
Plate Issued
Total
Rater #
Return #
Temp. Issued
VD-128 10/2017 MTC
Safety/Service Organization Special License Plate Application
120 State Street
DEPARTMENT OF MOTOR VEHICLES
Montpelier, Vermont 05603-0001
Agency of Transportation
(voice) 802.828.2000
Toll Free: 888-99-VERMONT
dmv.vermont.gov
TTD: 711
Last Name
First Name
Middle Initial
License #
Mailing Address
City
State
ZIP Code
Email
Phone
Current Plate No.
Model Year
Make
A one-time Safety/Service Organization
plate fee of $17.00 required.
Serial Number (VIN)
Professional Fire Fighters of Vermont
21
(Letter on company letterhead stating they are a member in good standing)
American Legion
38
(Copy of a valid membership ID card or letter of authorization from Post Adjutant)
Vermont State Firefighters Association Plate
40
(Authorization letter from V.S.F.A.)
Vermont National Guard Plate
41
(Authorization from Office of the Adjutant General, State of VT)
Vermont Amateur Radio Operator Plate
(Copy of Federal Communication Commission License)
42
FCC Call Sign:
VT Emergency Medical Services Plate [EMS]
46
(Authorization letter from VT Ambulance Association)
Vietnam Veterans of America
50
(Copy of a valid VT Membership card or signed authorization)
Lion’s Club
51
(Copy of membership ID card or letter of authorization from chapter officer)
Veterans of Foreign Wars
52
(Copy of valid membership card or an authorization signed by VFW Quartermaster)
Rotary International
53
(Copy of membership ID card or letter of authorization from chapter officer)
Grand Lodge of Vermont for Free Masons
54
(Copy of a valid membership ID card or letter of authorization from lodge secretary)
National Ski Patrol
68
(Copy of an active National Ski Patrol card)
STATEMENTS AND WARRANT MADE HEREIN ARE CERTIFIED UNDER PENALTY OF 23 V.S.A. § 202 & 203
Date
Signature of Applicant
DO NOT WRITE - DMV USE ONLY
 455
 465
 490 P
R
Veh. Type =
Reg Type =
92
Plate Type =
New Plate
 231  232
Date Issued:
Exp. Date
01
Special Plate
Old Plate No.
10
Miscellaneous
Plate Issued
Total
Rater #
Return #
Temp. Issued
VD-128 10/2017 MTC
Instructions and conditions for Safety/Service Organization Special License Plate
Name & Address Section:
THIS SECTION MUST BE COMPLETED IN FULL (Email and Phone are optional information.) OR THIS APPLICATION WILL BE
RETURNED TO YOU.
If the address given differs from what appears on our records, this will be considered a notification of change of address for all your
records. You are required to notify DMV within 30 days of any change in your mailing address, legal name or physical residence.
Vehicle Section:
The vehicle listed on the application must be registered in the name of the authorized applicant (owner, co-owner and lessee) or a Safety/Service
Organizations Plates plate will not be issued.
Applicants for Vermont Amateur Radio Operator plates must enter their FCC Call sign. Both “O” (ocean) and “0” (zero) will be allowed on
amateur operator plates only. The “O” (zero) must be clearly identified by a slash (/) mark.
Only eligible members of Safety/Service Organizations that have been authorized by their organization may apply for a Safety/Service
Organization plate.
Safety/Service Organizations Plates can be issues on Passenger Cars, Light Trucks and Trucks registered for less than 26,001 pounds and
excluding vehicles registered under the International Registration Plan.
A separate application must be made for plates for each vehicle.
Delivery may take up to 30 days from date of application. A temporary plate may be issued to the applicant if required.
License Plate Type:
Amateur radio operator plates are limited to a maximum of six characters including one numeric character. Fewer characters than six will be
automatically centered on the plate.
Personalized special “vanity” number plates are not permitted for Safety / Service Organization license plates.
If the vehicle is currently registered in Vermont only, the Safety/Service Organization plate fee of $17.00 is due. If the vehicle is not currently
registered in Vermont, complete a Registration Application. Submit all fees for registration, in addition to the Safety/Service Organization
plate fee and this application.
Signature:
Sign and date
Payment must be made in U.S. Funds. Do Not Send Cash.
VD-128 10/2017 MTC