Form Hsmv 83034 - Application For Florida National Guard, U.s. Reserve, Ex-Prisoner Of War, Pearl Harbor Survivor, Purple Heart, Us Paratrooper, Operation Iraqi Freedom, Operation Enduring Freedom, Gold Star, Or Fraternal Order Of Police License Plate
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2FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES
DIVISION OF MOTORIST SERVICES
APPLICATION FOR FLORIDA NATIONAL GUARD, U.S. RESERVE, EX-PRISONER OF WAR, PEARL HARBOR SURVIVOR,
PURPLE HEART, US PARATROOPER, OPERATION IRAQI FREEDOM, OPERATION ENDURING FREEDOM,
GOLD STAR, OR FRATERNAL ORDER OF POLICE LICENSE PLATE
******SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX COLLECTOR'S OFFICE OR LICENSE PLATE AGENCY******
See Reverse Side of this form for Provisions of Law and Instructions
1.
I, ____________________________________________ hereby certify that I am a legal resident of Florida, residing at
______________________________________________________________________________________________
(Address)
(City)
(State)
(Zip)
and I am the registered owner of the following described motor vehicle:
YEAR ____________ MAKE ________________TYPE _____________ CURRENT LICENSE PLATE NUMBER __________________________
TITLE NUMBER ____________________________ VEHICLE IDENTIFICATION NUMBER____________________________________________
OWNER/LESSEE'S:
DATE OF BIRTH ______/______/______ SEX
OWNER/LESSEE'S DL NUMBER__________________________________
Owner’s Email Address: ____________________________________________________________________________________
2.
This is to certify that I, ___________________________________________________, am an active/retired member of the
Florida National Guard or U. S. Reserve who is applying for the following as indicated:
U.S. Reserve License Plate
Florida National Guard License Plate (Choose from the following):
NOTE: An active Florida National Guard may be issued ONE FREE license plate/registration each year, however, any
Initial Registration ($225), specialty and/or personalized fees would still apply, if applicable.
A.
One Free Original Florida National Guard License Plate/Registration for Active Florida National Guard Member.
B.
One Free Original Regular/Specialty/Personalized License Plate/Registration for Active Florida National Guard Member in lieu of a National Guard plate.
C.
Free Annual Renewal of my current Florida National Guard/Regular/Specialty/Personalized License Plate (active Florida National Guard member).
D.
Retired OR Active Member of the Florida National Guard Applying for an Original National Guard License Plate (not exempt from fees).
E.
Active Member of the Florida National Guard License Plate Renewing their National Guard License Plate (not exempt from fees).
__________________________________________________
(Signature of the member for the above indicated license plate)
A RETIRED MEMBER MUST SIGN ABOVE AND PROVIDE PROOF OF THEIR RETIREMENT (This proof is only needed when an original is being applied for).
AN ACTIVE MEMBER MUST SIGN ABOVE AND ALSO HAVE THE FOLLOWING STATEMENT SIGNED BY THEIR FIRST SERGEANT OR COMMANDING OFFICER:
This is to certify that ________________________________________________ is an active member of the Florida
National Guard or U.S. Reserve.
______________________________________________________
______________________________________
(Signature of the First Sergeant OR Signature & Rank of Commanding Officer)
(Telephone Number of Sergeant/Commanding Officer)
3.
This is to certify that I, ________________________________________________, am applying (and providing proof of
eligibility, as listed below) for the following license plate as indicated:
Ex-Prisoner of War
Purple Heart
Pearl Harbor Survivor
US Paratrooper
Oper. Iraqi Freedom
Oper. Enduring Freedom
Gold Star
Fraternal Order of Police
Ex-Prisoner
Un-remarried Surviving Spouse
Proof from the U.S. Government of being a legal ex-prisoner of war while in the service of the Armed Forces of the
of War
of Ex-Prisoner of War
United States or as a civilian serving with the consent or authorization of the United States Government.
Purple Heart
Un-remarried Surviving Spouse
Proof from the U.S. Government of being a recipient of the Purple Heart Medal.
Medal Recipient
of Purple Heart Medal Recipient
Pearl Harbor
Proof of membership in the Pearl Harbor Survivors Association or proof of active military duty in Pearl Harbor on
Survivor
December 7, 1941.
Proof of completion of US Army Jump School or proof of decorated as a parachutist during military training.
US Paratrooper
($20 annual use fee and $5 processing fee is required).
Operation Iraqi Freedom
Proof of active or former military duty in Iraq during Operation Iraqi Freedom or in Afghanistan during Operation
Operation Enduring Freedom
Enduring Freedom.
Proof from the U.S. Government that the service member was killed while serving and proof of relationship to the
Gold Star
service member.
A copy of a notarized letter from the Florida State Lodge of the Fraternal Order of Police must be submitted stating
Fraternal Order of Police
that the applicant is a member of the lodge in good standing or a member of a lodge member’s family.
___________________________________________________
(Signature of the applicant for the above indicated license plate.)
HSMV 83034 (Rev. 06/11)
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