Form Dmv-54-Ca - Contractors Association Of West Virginia

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B) Vehicle Information

DMV-54-CA

REV 08/13

West Virginia Department of Transportation

Division of Motor Vehicles

1-800-642-9066

Application for a WV Contractors Association License Plate

PLATE SAMPLE

A) Applicant/Owner(s) Information ·

Use Name(s) of Owner(s) as shown exactly on current

registration card that you wish to register the license plate.

Applicant’s Name

Name(s) on Registration

Street Address

STATE

ZIP

CITY

B) Vehicle Information

Year

Title No.

Make

Current Plate No.

VIN No.

C) Insurance Information

E ective Dates of Policy From:

To:

Policy No.

Insurance Company

NAIC Number

Insurance Agent

D) Applicant Certi cation

I certify that all information on this application is true and correct and if I cease to be in good standing with the above organization, I will immediately

return the special license plate to the Division of Motor Vehicles.

(X)

(

)

Phone No.

SIGNATURE OF APPLICANT

DATE

PLEASE SEE REVERSE SIDE FOR INSTRUCTION

OFFICE USE ONLY BELOW THIS LINE

OFFICE STAFF INSTRUCTIONS:

Insert the plate numbers on the plate

diagram to the left and submit this form