New York State Police Chiefs'
Benevolent Association, Inc.
2649 Strang Boulevard, Suite 201
Yorktown Heights, New York 10598
Phone & Fax number (914) 788-7089
Current New York State Vehicle License Plate #:
Name (as it appears on your current registration): Date of Birth:
Last:
 First:
 Middle:
Street:
City:
 State:
 Zip:
County of Residence:
Telephone # (9am to 4pm):
Member Name:
Personalization, you may select a combination of six letters, numbers and blanks.
Please enter up to three choices:
1st choice: 2nd choice:


3rd choice:

Make check or money order payable to the Commissioner of Motor Vehicles and mail to:
New York State Police Chiefs' Benevolent Association, Inc.,
2141 Crompond Rd., Cortlandt Manor, NY 10567-2505
Standard CBA Plate initial cost (in addition to standard registration fee) $43.00
(Cost to renew is $25.00 in addition to standard registration fee, billed every two years)
Personalized CBA initial cost (in addition to standard registration fee) $68.00
(Cost to renew is $50.00 in addition to standard registration fee billed every two years)
New York State Department of Motor Vehicles
GENERAL CONSENT FOR RELEASE OF PERSONAL INFORMATION
I , authorize the New York State Department of Motor Vehicles to disclose or otherwise make available to CBA, my name, address, plate number and registration information during the time period in which I hold CBA Member plates issued by DMV.

Motorist's Signature:
State Of
County Of
On this day of before me personally
appeared(1st, 2nd, Month, Year)
to me known and who by being duty sworn, acknowledged to be person described in and who executed the foregoing consent and he/she duty acknowledged to me that he/she executed the same.

Notary Public:
Certification:
Authorized Signature and Seal:
Date:
Plate Number:
Contact: email: cba154@aol.com phone: 914-788-7089
Mailing Address: 2649 Strang Boulevard, Suite 104,Yorktown Heights, NY 10598
© 2004 NYCBA. All Rights Reserved.