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Nonemergency HOV Exemption Decal Application
Registered owners of for-hire nonemergency medical transportation vehicles must use this form to apply for an
HOV exemption decal.
When completed, take or mail this form with a check or money order for $18.25, payable to Department of
Licensing, to any vehicle licensing oce or mail to:
Special Plate Unit
Department of Licensing
PO Box 9909
Olympia, WA 98507-8500
Questions: contact Customer Service at 360.902.3770.
The registered owner must certify they have a contract or service agreement to provide transportation services for
medical purposes with one or more of the following entities (check all that apply)
:
Hospital Clinic Dialysis center
Other medical institution Retirement home Group home
Health insurance company Day care center Federal, state, or local agency or jurisdiction
Broker who negotiates these services on behalf of on or more of these entities
Applicant / Vehicle infor mation
Name of registered owner or representative (Last, First, Middle) 10-digit daytime phone
Email
Mailing address (Address or PO Box, City, State, ZIP code)
Current plate number Vehicle identication number (VIN) Year Make Model
Describe the primary purpose of vehicle use for the above selected entities
Acknowledgement
By signing my name, I certify that I have a contract or service agreement to provide transportation services
for medical purposes with one or more of the above entities. I acknowledge that I understand nonemergency
vehicle qualications and restrictions and will operate the vehicle as such. I understand the expiration of the
nonemergency HOV exemption decal will expire June 30, 2025, and will remove the decal at that time.
Date and place (city or county) signed Registered owner or Representative signature
If not signed by Registered owner, printed name of Owner representative
NOTE: Afx this decal to the back of the vehicle in the upper right corner either in window
or directly on vehicle.
AI-420-501 (R/10/23)WA
When completed, print this form and sign here.
