Form MV-410 - Professional Series Custom Plates Application - New York

*Only the three series shown to the left can be personalized, using as many as 6
spaces. The fee to order one of these personalized plates is $91.25
. Write 3 plate
number choices below. If you want to leave a space on the plate, put a period(.)
on the line where the space should be. If the ISA is required, only 5 spaces
are allowed. DMV reserves the right to reject, recall or cancel any plate that is
deemed objectionable. This includes plates that have already been issued.
If you have any questions, or need additional information, call 518-402-4838. --- ---
Return this completed form, the required proof and your payment to:
Department of Motor Vehicles, Custom Plates Unit, PO Box 2775, Albany NY 12220.
Payment Method: o Check o Money Order o MasterCard o Visa o American Express o Discover
Name (as it appears on credit card) _______________________________________________________________
Credit Card Number ____________________________________________ Expiration Date ______________________________________
Authorized Signature
- __________________________________________________________________________
Please do not send cash! Make check or money order payable to “Commissioner of Motor Vehicles”. Please allow 4 to 6 weeks for delivery.
The annual renewal fee for professional series custom plates (except NYS Dental Association plates) is $31.25 ($62.50 for CPA or DC or HT
personalized plates). The annual renewal fee for NYS Dental Association plates is $30.00. These fees are in addition to your vehicle
registration renewal fee. You will be billed for the plates every two years when you renew your registration.
o Certified Public Accountant (CPA)*
Chiropractor (DC)*
o Hypnotherapist (HT)*
(Provide proof of membership in NYSHA)
o Acupuncturist (ACU)
o Chiropractor (DCH)
o Dentist (DDS)
o Medical Doctor (MD)
(allowed more than one set)
o NYS Dental Association (DDS) o NYS Dental Association (DMD)
(Provide proof of membership in NYSDA) (Provide proof of membership in NYSDA)
o Professional Engineer (PE)
o Psychologist (PSY)
o Registered Architect (AR)
o Registered Nurse (RN)
o Registered Physician’s
Assistant (RPA)
o Veterinarian (VM)
o Visiting Nurse (VN)
o Optometrist (OD)
o Pharmacist (RX)
o Physical Therapist (PT)
o Podiatrist (DPM)
In New York State, custom plates are reserved for easy identification of vehicles owned by members of professional groups. They are subject to
the following regulations: your current registration must
be in the name of the professional person; and you must provide a copy of
your current NYS Department of Education (DOE) Registration Certificate with your order.
PLATE SERIES REQUESTED (First-time plate fees are listed after each series and do not include the registration fee):
l Plates are not ordered until we receive ALL required documents and fees.
l The next available number in the plate series will be assigned.
l Falsifying documents will result in cancellation of the custom plates.
l Plates will be mailed to the address on the vehicle’s registration file. If you have moved and you have not updated your
address on your registration record, please complete the Change of Address form MV-232.
Last Name
Mailing Address (Street & No., Apt. No.)
Business Address
Date of Birth
/ /
Signature (Sign Name in Full)
Professional License No.
Current Plate Number Vehicle Year
Vehicle Make
Zip Code
Zip Code
Daytime Phone No.
( )
MV-410 (7/15)
Amount Enclosed
$58.75 each set
IMPORTANT: Making a false statement in any registration application or in any proof or statements in connection with it, or deceiving or
substituting in connection with this application, is a misdemeanor under Section 392 of the Vehicle and Traffic Law, and may also result in the
revocation or suspension of the registration and/or the applicant’s license pursuant to regulations established by the Commissioner. The act of
renewing these plates shall constitute your certification that you remain eligible to continue holding these plates.
Choice 1 __ __ __ __ __ __ Choice 2 __ __ __ __ __ __ Choice 3 __ __ __ __ __ __
Do your current plates have the
International Symbol of Access?
o Yes o No
If you need the International Symbol of Access on your new plates and you do not have it on your current plates, you
must also submit a completed form MV-664.1
o Medical Doctor (MD) motorcycle plate - initial fee $35 - annual fee $18.75 (cannot be personalized)
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Form MV-410 - Professional Series Custom Plates Application - New York PDF

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