MV-917 (7-21)
www.dmv.pa.gov
APPLICATION FOR SHARE THE ROAD
REGISTRATION PLATE (JY)
Fee: $40
For Department Use Only Bureau of Motor Vehicles · 1101 S. Front St. · Harrisburg, PA 17104-2516
Check One: Leased Vehicle: r YES r NO
NOTE: If the vehicle is a leased vehicle, Form MV-1L, "Application for Lessee Information," must be completed and attached. Form MV-1L is available on our website at www.dmv.pa.gov.
A VEHICLE DESCRIPTION AND APPLICANT INFORMATION - Complete this section exactly as information appears on current registration card.
Title Number
Vehicle Identification Number
Registration Plate Number
Expiration Date
Make of Vehicle
Year
Last Name (or Full Business Name) Co-Owner Last Name
First Name First Name
Middle Name Middle Name
PA DL/Photo ID# or BUS. ID#
PA DL/Photo ID#
Date of Birth Date of Birth
Street Address
City
State
Zip Code
Telephone Number: HOME: ( ) _____________________ WORK: ( ) ______________________
NOTE: In conjunction with replacement of your registration plate, you will receive one registration card. If additional registration cards are desired, the fee is $2 for each registration card. Number of duplicate registration cards requested @ $2 each: _________.
B OPTIONAL PERSONALIZATION REQUEST - NOTE: Additional $112 fee required.
Personalized Share the Road registration plate choices may contain up to FIVE letters or numbers in combination. ONLY one hyphen or space is permitted as part of the FIVE available spaces for personalization. No other special characters are available. Please use capital letters and print clearly. Additional instructions are listed on the reverse side of this application. NOTE: The shaded boxes with a pre-printed letter configuration of "BK" are specific to this registration plate and cannot be changed. These letters will appear on your personalized registration plate.
FIRST CHOICE
B K
SECOND CHOICE
B K
THIRD CHOICE
B K
NOTE: When requesting a numeric character of zero, please show as "0/ " instead of the alpha character "O." Since this is an electronically fillable form, after printing the form please be sure any zero is marked with a "/."
C APPLICANT(S) SIGNATURE
I/We hereby certify under penalty of law that ALL information contained herein is TRUE and CORRECT and that I/we understand that any misstatement of fact is a misdemeanor of the third degree punishable by a fine up to $2,500 and/or imprisonment up to 1 year (18 Pa.C.S. Section 4904[b]).
Signature of Applicant Signature of Co-Applicant
Date Date
SHARE THE ROAD
Show your support of bicycling by displaying Pennsylvania's Share the Road registration plate. This registration plate was established by Act 36, referred to as the David (Dave) Bachman Act, which was enacted in June 2016 in memory of a PennDOT employee who served as the Department's first Bicycle/Pedestrian Coordinator. All proceeds from the purchase of this registration plate will help fund the Department's Bicycle & Pedestrian safety efforts, as well as highway infrastructure signage for bicyclists with the purpose of wayfinding and/or safety.
GENERAL INFORMATION
· Fee required with this application is one check or money order in the amount of $40. (An additional $112 fee is required for personalization requests.) Payment is to be made by check or money order payable to the Commonwealth of Pennsylvania. DONOTSENDCASH. NO REFUND of the fee will be issued when an applicant cancels the request for a Share the Road registration plate after the order is placed.
· No Share the Road registration plate will be duplicated. If your registration plate is lost, stolen or defaced, you will need to reapply for a Share the Road registration plate by completing this application and submitting with the appropriate fees. Should you need an immediate replacement registration plate, please complete and submit Form MV-44, "Application for Duplicate Registration Card, Replacement of Registration Plate or Weight Class Sticker," along with a fee of $11. A standard registration plate will be issued until the replacement registration plate can be provided. (NOTE: Form MV-44 is available on our website at www.dmv.pa.gov.)
· Requests for the Share the Road registration plates are restricted to passenger cars or trucks with a registered gross weight of not more than 14,000 pounds or a motor home.
· This application, completed in full, along with a check or money order should be mailed to: Bureau of Motor Vehicles, Special Tag Unit, P.O. Box 67900, Harrisburg, PA 17106-7900.
· All telephone numbers will be held in confidence and used only in the event of a problem with your application. · 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.
IF PERSONALIZING YOUR REGISTRATION PLATE
· Personalized Share the Road registration plates may contain up to FIVE letters and numbers in combination. NOTE: A preprinted letter configuration of "BK" will precede your personalized configuration on your registration plate and cannot be changed.
· If a hyphen or space is used as part of the registration plate configuration, it counts as one of the available spaces for personalization. Only one hyphen or space is permitted, but not both. NOTE: No additional special characters are available.
· Please use capital letters and print clearly. When requesting a numeric character of zero, please list as "0" instead of the alpha character of "O".
· PennDOT reserves the right to limit or reject certain requests. · The fee to personalize your registration plate is an additional $112, and the registration on your vehicle must be current in order for
PennDOT to process your request. The additional $112 fee covers the cost of your personalized registration plate order only and will not renew your vehicle's registration. If your registration has expired or expires in the next three months, please include your completed renewal application, Form MV-105, "Pennsylvania Registration Renewal Application," or Form MV-140, "Request for Registration," and a separate check or money order in the amount of your registration renewal fee. Payment is to be made by check or money order payable 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.pa.gov, and select Plate Availability from the list of services under the Online Services heading. Personalized registration plates will not be reserved until PennDOT receives payment and a completed application, and approves your requested registration plate configuration [number(s) and/or letter(s)]. Please note that registration plate requests are processed on a first-come, first-served basis. Although a requested registration plate configuration may show as being available on the website, it is possible that a request for the same registration plate configuration may have already been submitted by another customer 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 an applicant cancels a request after the order is placed with the manufacturer. · Allow eight to 10 weeks for delivery.
Visit us at www.dmv.pa.gov or call us at 717-412-5300. TTY callers -- please dial 711 to reach us.