Form MV-400PH - Request for Custom Empire Plates - New York
Second Choice:
JOE
ORDER OF PREFERENCE (use letters and numbers only):
1
1
2
2
4
4
5
5
6
6
3
3
1
24563
Custom plates are manufactured in most combinations of as many as six letters and/or numbers on a first-come, first-
served basis. The plate number you request must include at least one letter. Each plate will have a reproduction of the
International Symbol of Access on the right side of the plate. You may include a State silhouette anywhere except at
the beginning of the plate number by placing the @ symbol in the box where you want the silhouette to appear. Also,
if you want a space between any letters/numbers, place a period (.) in the box(es) where you want a space.
u Letters (A thru Z) and numbers (0 thru 9) can be entered in a box.
u Other symbols, including dashes (-), may not be used. A period (.) in a box will be a blank space on the plate.
u To distinguish between the letter “O” and a zero, put a slash thru a zero (0). The slash will not appear on the plate.
u To distinguish between the letter “I” and the number “1”, use a capital “I”.
To request your custom plate numbers, fill in your choices in the boxed area below. Use the following guidelines:
In the “Choice” boxes below, write the combination of letters and numbers (not more than six) you want on your plate. You may select, in
order of preference, as many as three different combinations of letters and numbers. For each choice, enter each letter or number exactly as you
want it to appear on the plate. Place a period (.) in any box where you want there to be a space on the plate. Place the @ symbol where you
want a State silhouette to appear.
DO NOT WRITE IN THIS SPACE - FOR DMV USE ONLY
...............................................................................................................................................................................................
1
M
1
J
2
Y
2
O
4
C
4
E
5
A
5
P
6
R
6
H
3
@
3
S
MV-400PH (4/11)
PAGE 2 OF 3
EXAMPLE
In this example, your choice of plate numbers, in order of your preference, are: My Car (with the State silhouette), Joe and Joseph.
First Choice:
MY CAR
Third Choice:
JOSEPH
First Choice:
Second Choice: Third Choice:
Please Do Not Send Cash! If paying by check or money order, please make it payable to the “Commissioner of Motor Vehicles”.
Payment Method: o Check o Money Order o Master Card o Visa
o American Express o Discover
Name (as it appears on credit card) ______________________________________________________
Card Account Number ________________________________________________________ Expiration Date ________________________
Authorized Signature
ç ______________________________________________________________
If you have any questions, call (518) 402-4838 or visit us at: www.dmv.ny.gov
Amount Enclosed $ _______________________
REQUEST FOR CUSTOM EMPIRE PLATES FOR A DISABLED REGISTRANT
METHOD OF PAYMENT
PART 3
PART 4
1
l
2
l
3
J
5
E
6
l
4
O
You must explain the meaning of your letter/number combination. DMV reserves the right to reject, recall or cancel any plate that is
deemed objectionable. This includes plates that have already been issued.
1st Choice ________________________________________________________________________________________________
2nd Choice ________________________________________________________________________________________________
3rd Choice ________________________________________________________________________________________________
REQUIRED
Page 2/3
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Form MV-400PH - Request for Custom Empire Plates - New York PDF
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