Hunting Heritage License Plate Application Directions1. Download applicati on. Adobe Acrobat is required for this form.2. Fill out Secti on A3. Sign the applicati on, Secti on E4. Make check payable to Pennsylvania Game Commission for the “Total Amount Due” shown below5. Mail order form, applicati on and check to: Department MS, Pennsylvania Game Commission,

2001 Elmerton Ave., Harrisburg PA 17110-97976. Please allow 6 – 8 weeks for delivery to your home.

Hunting Heritage License Plate Frequently Asked Questions1. License Plate Fee: $56.002. Personalized Plates: Plates are issued in sequenti al order only and cannot be personalized in any manner.3. Handicap Plates: Specialty plates cannot add a handicap insignia; however, the hanging placard will aff ord

you the same privileges as the disability plate.4. Registrati on: Do not let your registrati on lapse! Renew your registrati on as normal. Purchasing this plate

does not automati cally renew your registrati on. You will not be paying twice by paying for this specialty plate, as the $56.00 is the total fee for the plate and does not aff ect your registrati on. When your new plate arrives, it will have a new registrati on card and sti cker with your expirati on date. It does not matt er where in the vehicle registrati on cycle that you get this plate.

5. When: Since the plates are made in consecuti ve order as applicati ons are submitt ed, and are not pre-made – once PennDOT receives an applicati on it takes about 6 weeks for the plate to arrive in your mailbox.

6. No specialty plates will be duplicated if lost – you will need to reapply. No fees will be refunded if applicant cancels request aft er order is placed.

Mail Order Form to:Department MS, Pennsylvania Game Commission, 2001 Elmerton Ave., Harrisburg, PA 17110-9797Visit “The Outdoor Shop” at www.pgc.state.pa.us

Return Policy: (1) Examine all items carefully upon receipt. (2) Returns will be accepted only due to a manufacturer defect. (3) Defecti ve item(s) must be returned within 10 days of receipt, along with the complete packing slip to: Department of MS, Pennsylvania Game Commission, 2001 Elmerton Ave., Harrisburg, PA 17110-9797

Shipping & Handling Charges

$1.00 to $6.00 = $1.25

$6.01 to $20.00 = $2.95

$20.01 to $35.00 = $4.95

$35.01 to $60.00 = $6.95

$60.01 to $100.00 = $8.95

$100.01 to $150.00 = $10.95

$150.01 to $200.00 = $12.95

$200.01 to $250.00 = $14.95

$250.01 to $300.00 = $16.95

$300.01 to $350.00 = $18.95

$350.01 to $400.00 = $20.95

$400.01 to $450.00 = $22.95

$450.01 to $500.00 = $24.95

$500.00 = $30.95 over

Hunting Heritage License Plate Products Quantity Price Total

Hunting Heritage 4” Patch $5.66

Hunting Heritage 4” Decal $2.83

Product Sub Total

Shipping & Handling (see chart)

Sub Total

Pennsylvania Residents add 6% Sales Tax

Hunting Heritage License Plate $56.00

Total Amount Due

Name: _________________________________________________________________________ Date: _________________________________

Address: _______________________________________________________________________________________________________________

Phone Number: ___________________________________________ E-mail:____________________________________________________

Payment Method [ ] Check [ ] Credit Card #: Exp. Date:Signature:

Home ( ) _______________Office ( ) _______________

Title Number Registration Plate Number Expiration Date Make of Vehicle Year

Last Name (or Full Business Name) First Name Middle Name PA DL/Photo ID# or Date of Birth TelephoneBus. ID#

Street Address - Must list a street address. P.O Box # alone is not acceptable. City State Zip Code

I certify that the individual named in Section A is a member in good standing of the organization listed in Section B.

MV-904SP (10-14)

www.dmv.state.pa.us

ApplicAtiOn FOr SpEciAlOrgAniZAtiOn rEgiStrAtiOn plAtE

For Department Use OnlyBureau of Motor Vehicles • PO Box 68293 • Harrisburg, PA 17106-8293(PLEASE ALLOW 4-6 WEEKS FOR DELIVERY)

xAPPLICANT’S SIGNATURE IN INK DATE

Name of Organization, Chapter, Post, Lodge, Employer, etc.

Street Address City State Zip Code

NAME OF ORGANIZATION OFFICIAL TITLE SIGNATURE

I certify that all information given on this application is TRUE and CORRECT and that when I cease to be a member of the above named organization, Iwill immediately return the registration plate to PennDOT.

Personalized registration plate choices may contain up to FiVE letters or numbers in combination. OnlY one hyphen or space is permitted, but notboth as part of the available spaces for personalization. No other special characters are available. Please print clearly. Additional instructions andfees are listed on the reverse side of this application. nOtE: The pre-printed, shaded, stacked boxes are characters specific to this registration plateand cannot be changed.

nOtE: In conjunction with replacement of your plate, you will receive one registration card. If additional registration cards are desired, the fee is $2for each card. number of Duplicate registration cards requested @ $2 each _________.

nAME OF OrgAniZAtiOn:

FIRST CHOICE SECOND CHOICE THIRD CHOICE

A VEHiclE DEScriptiOn AnD ApplicAnt inFOrMAtiOn (Complete this section exactly as information appears on current registration card.)

B tO BE cOMplEtED BY OrgAniZAtiOn OFFiciAl

c tO BE cOMplEtED BY OrgAniZAtiOn OFFiciAl (See special instructions on reverse.)

D OptiOnAl pErSOnAliZAtiOn rEQuESt (nOtE: Additional $100 Fee required.)

E ApplicAnt SignAturE

gEnErAl inFOrMAtiOn rEgArDing A SpEciAl OrgAniZAtiOn plAtE• plEASE AllOw 4-6 wEEkS FOr DEliVErY.• this application, with Sections A, D (if applicable), and E, completed in full, must be returned to the organization official for

submission to pennDOt. No applications sent directly to PennDOT by the organization member will be processed. The organizationmust complete Sections B and C.

• the applicant listed in Section A must be a registered owner of the vehicle as indicated on the vehicle’s registrationcredential. If the vehicle is a leased vehicle, Form MV-1L, “Application for Lessee Information,” must be completed and attached.(nOtE: Form MV-1L is available on our website at www.dmv.state.pa.us.)

• PennDOT charges an issuance fee of $25. Participating organizations may charge an additional fee above the $25 PennDOT fee.The organization fee is $__________. Therefore, the total fee due with this application is $__________. Fees must be made payableto the organization name of __________________________________________________________________________________.

• No special organization registration plate will be duplicated. If your plate is lost, stolen or defaced you will need to reapply for a specialorganization registration plate by completing this application and submitting it with the appropriate fees. Should you need animmediate replacement plate, please complete and submit Form MV-44, “Application for Duplicate Registration Card, Replacementof Registration Plate, Renewal Sticker or Weight Class Sticker," along with a fee of $11. A standard issued plate will be issued untilthe replacement special organization registration plate can be provided. (nOtE: Form MV-44 is available on our website atwww.dmv.state.pa.us.)

• Requests for special organization registration plates are restricted to passenger vehicles, trucks with a registered gross weight of notmore than 14,000 lbs., trailers and motor homes. Motorcycles do not qualify for special organization registration plates.

• nO rEFunD of the fee will be issued when an applicant cancels a request after the order is placed.• When the applicant ceases to be a member in the organization as listed in Section B, the registration plate must be returned toPennDOT. Complete Form MV-44 and submit a fee of $11 for the issuance of a regular series registration plate.

• Special organization registration plates are issued in number sequence unless requesting personalization in Section D.• To avoid possible problems with citations with your old registration plate, return it to: Bureau of Motor Vehicles, Return Tag Unit, P.O.Box 68597, Harrisburg, PA 17106-8597 after you have received your special organization registration plate.

• If applying for a Fraternal Order of Police plate, the PA State Lodge Seal and the PA State Lodge Recording Secretary signature mustbe affixed to this application.

iF pErSOnAliZing YOur SpEciAl OrgAniZAtiOn rEgiStrAtiOn plAtE• Personalized special organization registration plates may contain up to FiVE letters and numbers in combination.• If a hyphen or space is used as part of the registration configuration, it counts as one of the available spaces for personalization. Onlyone hyphen or space is permitted, but not both. nOtE: No additional special characters are available.

• When requesting a numeric character of zero, please list as " " instead of the alpha character of "O".• PennDOT reserves the right to limit or reject certain requests.• The registration on your vehicle must be current in order for PennDOT to process your request. The fee to personalize your specialorganization registration plate is an additional $100. the additional $100 fee covers the cost of your personalized registrationplate order only and will not renew your vehicle's registration. To renew your registration, please include your completed renewalapplication, Form MV-105, “Pennsylvania Registration Renewal Application,” or Form MV-140, “Request for Registration,” and aseparate check or money order in the amount of your registration renewal fee. Payment is to be made by check or money orderpayable to the Commonwealth of Pennsylvania. plEASE DO nOt SEnD cASH.

• To check personalized registration plate availability, visit PennDOT’s Driver and Vehicle Services website, www.dmv.state.pa.us, andselect the Personalized Registration Plate Availability link from the list of services under the Online Driver and Vehicle Servicesheading. Personalized registration plates will not be reserved until PennDOT receives payment and a completed application, andapproves your requested registration plate configuration [number(s) and/or letter(s)]. Please note that registration plate requests areprocessed on a first-come, first-served basis. Although a requested registration plate configuration may show as being available onthe website, it is possible that a request for the same registration plate configuration may have already been submitted by anothercustomer and may not be available when making application.

• Personal registration plates will be manufactured on the basis of this application. nO rEFunD of the fee will be issued when anapplicant cancels a request after the order is placed with the manufacturer.

• Allow eight to 10 weeks for delivery of personalized special organization plate.

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Visit us at www.dmv.state.pa.us or call us at:In state: 1-800-932-4600 u TDD: 1-800-228-0676 u Out-of-State: 1-717-412-5300 u TDD Out-of-State: 1-717-412-5380