Application for Legislative License Plate

In the State of Florida, if a person wishes to apply for legislative license plates, he/she has to use the following application form.

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STATE OF FLORIDA 
DEPARTMENT OF HIGHW AY SAFETY AND MOTOR VEHICLES 
Office of Legislative Affairs 
2900 Apalachee Parkway, MS# 01 
Neil Kirkman Building – Tallahassee, FL 32399-0500 	
 
 	
A PP L I C A T I O N  F O R  L E G I S L A T I V E  L I C E N S E  P L A T E 	  	
Do NOT submit this form to your local office. Contact Legislative Affairs at 850-617-3195 	 	
I hereby make application for:   Legislator’s Name: _________________  
  District Number:     _________________ 
 
(Please Check One) 	
 	
Official Congress License Plate  Retired House 
Official House License Plate 	
 Retired Congress 
Official Senate License Plate 
 Retired Senate 
Senate President 
 House Speaker 	
INSTRUCTIONS	 	
 	
1)  Carefully read all information on the front and back of the application before completing the 
application. 
2)  Complete the application form and submit it with the following items:  
a.  Copy of your current Florida Vehicle Registration Certificate, registration renewal notice, or title 
b.  Proof of Florida insurance Personal Injury Protection (PIP) and Property Damage Liability 
(PDL) submitted in the form of a card, policy, binder, certificate of insurance, or affidavit  
c.  Remittance fees (payable to: Division of Motorist Services).  Contact the Office of Legislative 
Affairs for questions concerning fees. 
3)  Please allow six to eight weeks for the manufacture and delivery of the license plate.  
 
  	
OWNER/APPLICANT IDENTIFICATION 	
Contact Name 	Contact Number 	
Owner’s Name 	Date of Birth 	
Street Address 	City 	State 	Zip 	
Owner’s E-Mail Address 	Owner’s Driver’s License or Identification # 	
Co Owner’s Name 	Date of Birth 
 	
Street Address 	City 	State 	Zip 	
Co Owner’s E-Mail Address 	Co Owner’s Driver License or Identification #

VEHICLE INFORMATION 	
Title Number 	Current License Plate Number 	Vehicle Identification Number 	
Vehicle Make 	Year 	Color 	Vehicle Type 	
  
 
 	
Four (4) characters are allowed for each legislative plate authorized. Your choice of 
characters may include letters and numbers. 
The graphic design is on the far left side of the plate allowing for four characters on the far 
right side. See the sample legislative license plates shown below. Additional plate designs 
can be found in the legislative plate brochure. 	
 
 	
 	  
 	
List your preferences for the plate configuration below. 	
 	
1st Choice Configuration _ _ _ _  2nd Choice Configuration _ _ _ _ 	
 	
3rd Choice Configuration _ _ _ _  4th Choice Configuration _ _ _ _ 	
 	
5th Choice Configuration _ _ _ _ 	
 
 	
An application must be completed for each vehicle. For an original license plate, please DO 
NOT submit this completed application to your local Tax Collector Office or License Plate 
Agency. Submit it to the address at the top of the form or fax to 850-617-5207. Once the 
license plate has been issued, your local Tax Collector Office or License Plate Agency may 
process renewals and transfers. 	
 
 	
For additional license plates or questions concerning the license plate fees, please contact the Office of 
Legislative Affairs at (850) 617-3195. 	
  
 
 
 
 
 
 
 
 
 
 	
HSMV 83109 (REV. 08/16) www.flhsmv.gov