Application for Amateur Radio License Plate

Applying for an amateur radio license plate requires the use of the following application form. Complete the form accurately and submit it to the local tax collector’s office.

Extracted Text for Proper Search

State of Florida 	 	
DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES DIVISION OF MOTORIST SERVICES  	
SUBMIT APPLICATION TO YOUR LOCAL COUNTY TAX CO LLECTOR'S OFFICE OR LICENSE PLATE AGENCY 	www.flhsmv.gov/offices/	 	
APPLICATION FOR AMATEUR RADIO LICENSE PLATE 	 	
OWNER / APPLICANT IDENTIFICATION 	
Owner’s First Name, Full Middle/Maiden Name, Last Name  Owner’s E-Mail Address 
Owner’s FL Driver License, Identification Card or FEID/Suffix	 #  Sex  Date of Birth	 	
Co-Owner’s First Name, Full Middle/Maiden Na me, Last Name  Co-Owner’s E-Mail Address 
Co-Owner’s FL Driver License, Identification Card or FEID/Suffix	 # Sex  Date of Birth	 	
Lessee’s First Name, Full Middle/Maiden Na me, Last Name  Lessee’s E-Mail Address 
Lessee’s 	FL Driver License, Identification Card or FEID/Suffix	 # Sex  Date of Birth	 	
Owner’s Mailing Address  City State  Zip 
Co-Owner’s / Lessee’s Mailing Address (If Diffe rent from Owner's Address)  City  State  Zip 
Owner’s or Lessee’s Street Address in Florida (Mandatory)  City State  Zip 	
MOTOR VEHICLE DESCRIPTION  	
Vehicle Identification Number YearColorMake  Body
License Plate Number  Florida Title Number	 	Weight	
CERTIFICATION  I certify that I am a legal resident of the State of Florida. I further \
certify that I am the holder of a 
non-revoked and non-expired official Amateur Radio Station License recognized by the Federal 
Communications Commission. 	
Signature of Licensed Amateur Radio 
Operator Assigned Call Letters  Dated 	
APPLICATION REQUIREMENTS 	 
These license plates may only be issued for the follo wing types of vehicles:  
1. Automobiles for private use and for-hire.	 	
2. Trucks weighing 7,999 pounds or less. 
3. Motor homes or truck campers which ar e NOT "for hire" or "commercial" use. ♦
The applicant must be a Florida resident and must hold a valid amateur 
radio station licens	
e rec	ognized by 
the Federal Communications Commission.	
   HSMV 83041, Application for Amat eur Radio License Plate, must be legibly completed in full. 	 	
  Proof of Florida insurance indicating personal in jury protection and property damage liability coverage is 
required. (Applicant may submit a c opy of their insurance card, policy or binder, or may complete the 
insurance affidavit form HSMV 83330.) 	
 	
   Submit a copy of your current  vehicle registration certificate. 	 	
  Submit a copy of your Am ateur Radio Station License. 	 	
  Contact your local county tax collector's offi ce or license plate agency for fee information.  Check your local phone book government pages or visit 
the following website for current mailing addresses: 
http://www.flhsmv.gov/offices/  
HSMV 83041 (REV.  06/1	

4) S  www.flhsmv.gov