Form Mv-Psfr - Public Safety First Responder License Plate Application - Georgia
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1MV-PSFR (Revised 11-2015)
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Georgia Department of Revenue - Motor Vehicle Division
Public Safety First Responder License Plate Application
Purpose of this Form: This form is to be used by any Public Safety First Responder who has received a major injury in the line of duty to apply
for a Public Safety First Responder license plate. This form should not be used to record a change of ownership, change of address, or change
of license plate classification.
How to submit this Form: This completed form must be submitted to your local county tag office. Please refer to our website at
to locate the address(es) for your specific County.
Special Plate Fees: Manufacturing Fee: $25.00 (one time fee), Annual Registration Fee: $20.00, Annual Special Tag Fee: $35.00
A
REGISTRANT INFORMATION
First Name
Middle Initial
Last Name
Suffix
Registrant’s
Full Legal Name:
Mailing Address:
City:
State:
Zip:
Telephone Number:
B
VEHICLE INFORMATION
Vehicle Identification Number (VIN):
Year:
Make:
Model:
C
EMPLOYMENT INFORMATION
Organization’s Name:
Occupation:
Law Enforcement Officer
Emergency Medical Services Personnel
Other ____________________
(Check One)
Firefighter
Ambulance Driver
By signing this application, you are attesting to the fact that:
(A) You suffered an injury in the course of your official duties;
(B) Your injuries required hospitalization or comparable medical treatment which resulted in permanent disability or disfigurement of the
body.
Registrant’s Signature
Date
D
CERTIFICATION FROM EMPLOYER (To be completed by the Employer)
I certify that the information contained in Section C is true, complete, and correct to the best of my knowledge and belief and that I am an
authorized official of the organization named in Section C.
Authorized
Title:
Official’s Name:
Telephone Number:
E-mail:
Authorized Official’s Signature
Date
Have a question? Visit our website at
/motor-vehicles
or scan the QR code above for more information.
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