Form Vco/tr-715pr - Personalized Plate Application
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1P
M
T
C
F
C
U
OUNTY
SE
LEASE
AIL OR
AKE THIS
OMPLETED
ORM WITH
PERSONALIZED PLATE
O
A
F
Y
NLY
PPROPRIATE
EE TO
OUR
C
T
’
OUNTY
REASURER
S
APPLICATION
$
M
V
O
OTOR
EHICLE
FFICE
Fee Collected
V
O
I
EHICLE
WNER
NFORMATION
Name:
Dr. Lic. #:
Daytime Phone #: (
)
KS
Address
City
State
ZIP
V
I
EHICLE
NFORMATION
Year
Make
Style
VIN
Truck
Current License
Registration
Vehicle Type
Registration Wt. of: 12M, 16M or 20M
Auto
Motorcycle
Plate Number:
(Tag) Expires: Mo
Yr
(Check O
One):
NLY
Auto and Truck: Personalized plates shall not contain more than 7 letters or numbers or a combination of letter and numbers. Personalized
disabled plates shall not contain more than 5 letters or numbers or a combination thereof.
Motorcycle: Personalized plates shall not contain more than 5 letters or numbers or a combination of letter and numbers.
Dashes and symbols are not acceptable/cannot be used; instead leave a blank space.
FEES*
Letters &/or numbers combination cannot be profane, vulgar, lewd or have an indecent meaning.
A
T
C
:
$45.50
Regular
Antique
UTO OR
RUCK
OMBINATION
or
(Must have Kansas antique title.) ..................
First Choice
One (1) character per box
Second Choice
One (1) character per box
Third Choice
One (1) character per box
M
OTORCYCLE OR
D
A
/T
C
:
$45.50
Regular
Antique
ISABLED
UTO
RUCK
OMBINATION
or
(Must have Kansas antique title.) ..................
First Choice
One (1) character per box
Second Choice
One (1) character per box
Third Choice
One (1) character per box
D
M
C
.........................................................................................$45.50
ISABLED
OTORCYCLE
OMBINATION
First Choice
One (1) character per box
Second Choice
One (1) character per box
Third Choice
One (1) character per box
(
):
I
/M
C
REQUIRED
NTERPRETATION
EANING OF
OMBINATION
*
Fee is for reservation of the personalized combination and
annual registration fee or one time antique registration fee.
DOES NOT INCLUDE
I declare under penalty of perjury under the laws of the state of Kansas that the foregoing is true and correct. I understand, and agree,
once the personalized plate is manufactured there can be no refund of the fee listed herein.
Owner’s:
Signature
Hand Printed Name
Date Executed
Accepted By
,
County Treasurer of
County
I
NSTRUCTIONS
1. Application for personalized license plates shall be made at your County Treasurer’s motor vehicle office.
2. Application must be signed by the applicant and include the appropriate fee. Make check payable to the County
Treasurer for your county.
3. Application for disabled personalized plate(s) are required to submit a copy of applicant’s current Disabled ID card or
a completed Certification of Disability for Disabled Parking Placard &/or Plate, form TR-159, signed by a healing arts
professional.
VCO/TR-715PR (Rev. 10/12)
Kansas Department of Revenue; Vehicles Central Office Operations
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Parent category: Financial