LOUISIANA DEPARTMENT OF PUBLIC SAFETY
AND CORRECTIONS
OFFICE OF MOTOR VEHICLES
P.O. Box 64886
ATTN:  Special Plates
Baton Rouge, Louisiana 70896-4886

REQUEST FOR Special PLATES
For: Private Passenger vehicles as provided for in RS 47:490:ET AL

Date of Application :  10/23/2014


Name:  *
Louisiana Address Line 1:  *
Louisiana Address Line 2: 
City:  *
State:  Louisiana
Zip:  *
Is mailing address same?  Yes   No
Other Address: 
Other City: 
Other State: 
ZIP: 
Email Address: 
Driver's License Number:  *
Present License Plate No. on Vehicle: 
Type of Plate selected:      ()
   
Enclose check or money order for: 
   
While every attempt is made to provide an accurate fee for this service, the state of Louisiana OMV reserves the right to reject payment for Special Plates if fees are incorrect.
   
Enclose the following documents: 

* = Required

Print this form and mail to the above address.