Motor Vehicle Administration 6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

VR-096 (03-11)
Fee: $51.00/2 years Last Date of Birth (mm/dd/yyyy) City or Town Middle County State Last Date of Birth (mm/dd/yyyy) Zip Code

Application for Historic or Street Rod Registration

Please print all information
Owners First Name Owners Maryland Drivers License Number Owners Resident Address Co-Owners First Name Co-Owners Maryland Drivers License Number Middle

Description of Vehicle
Year Make Model Body Style Vehicle Identification Number (VIN) Title Number

Insurance Company Name

Policy/Binder #

I/We, the owner(s) of the vehicle described above, apply for a registration for an historic motor vehicle because (please check the one block that applies):

The vehicle is 20 calendar years or older and has not been substantially altered, remodeled or remanufactured from its original construction.

The vehicle is 60 calendar years or older and has not been substantially altered, remodeled or remanufactured from its original construction.

ONE-TIME REGISTRATION FEE OF $50.00 THAT IS NOT TRANSFERABLE TO A SUBSEQUENT OWNER. Motor Homes, Tow Trucks, Tractors and Trailers do not qualify for Historic or Street Rod Registration. Note: Historic motor vehicles 60 years or older do not qualify for special registration plates as they require an annual registration fee. The vehicle must be identifiable by a vehicle identification number (VIN) which is a distinct series of numbers assigned by the manufacturer within a general group of numbers as verified by the manufacturer.

MVA Use Only

Tag Number Issued:

I/We, the owner(s) of the vehicle described above, apply for registration of the vehicle as a Street Rod Vehicle on the following basis:

q The vehicle is 25 calendar years or older and has been substantially altered from the manufacturers original design.
I/We, certify under oath that the vehicle will only be maintained for use in exhibitions, club activities, parades, tours, occasional transportation and similar uses. I/We further certify that this vehicle will not be used for general daily transportation or primarily for the transportation of passengers or property on highways.

Signature of Owner

Date

Signature of Co-Owner

Date

Please make checks or money orders payable to the MVA. The check must include: (1) Imprinted name and address, (2) Drivers license number (or FEIN, if company owned) and (3) Home or work telephone number. For more information, please call: 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov