Form DS-100 APPLICATION FOR REGISTRATION (MISSION VEHICLE)

APPLICATION FOR REGISTRATION (MISSION VEHICLE)
INSTRUCTIONS
1. In addition to this form, you must submit:
a. The original ownership document(s): the Certificate of Origin (for a new vehicle) or the state's certificate of title (for a used vehicle) and all
corresponding re-assignment pages.
b. A photocopy of the insurance binder sheet or the declaration page. You must have liability coverage of $100,000 Bodily Injury/Person;
$300,000 Bodily Injury/Accident; $100,000 Property Damage/Accident; or $300,000 combined single limit.
c. Odometer Statement complete with signatures of the buyer and seller (for new vehicles only).
2. You must type all answers, or write them in block letters.
3. Always write names with surname first, then first name, then middle name or initial. Spell your name exactly as it was given to the Office of
Protocol. Applications with names different from the accreditation record will be returned for correction.
4. Always write dates month first, then day, then year. Always write the month and give the day and year in numbers only. Always give your date of
birth (DOB) exactly as it was given to the Office of Protocol. Applications with a date of birth different from the accreditation record will be returned
for correction.
5. Copy all the motor vehicle information from the Certificate of Origin or state's certificate of title. Be very careful when copying the vehicle
identification number (VIN).
6. If applicable, provide the name and address of the bank or other institution with a financial interest (lien) in the motor vehicle.
7. You must sign and date the application, and it must bear the Mission seal.
PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to Vienna Convention on Diplomatic Relations of 1961; Vienna Convention on Consular Relations
of 1963; Diplomatic Relations Act (22 U.S.C. 254a-e); International Organizations Immunities Act (22 U.S.C. 288e (a)); Foreign Missions Act of 1982
(22 U.S.C. 4301-4316) as amended.
PURPOSE: The information solicited on this form will be used to adjudicate requests for registration of foreign missions' mission vehicle(s).
ROUTINE USES: The information provided on this form may be provided to other federal agencies for law enforcement, administrative or other
statutorily authorized purposes as covered under STATE 36, Security Records. This information also may be provided to the employing foreign
government or international organization.
DISCLOSURE: Providing this information is voluntary; Failure to provide the information requested on this form may result in denial of registration of
foreign missions' mission vehicle(s).
PAPERWORK REDUCTION ACT STATEMENT
*Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the
accuracy of this burden estimate and/or recommendations for reducing it, please send them to: M/OFM, 3507 International Place NW, Washington,
DC 20008.

DS-100
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Instruction Page 1 of 1

U.S. Department of State
OFFICE OF FOREIGN MISSIONS
DIPLOMATIC MOTOR VEHICLE OFFICE

OMB Approval No. 1405- 0105
Expires xx-xx-xxxx
Estimate Burden 15 minutes*

APPLICATION FOR REGISTRATION (MISSION VEHICLE)
SEE INSTRUCTION PAGE
Country

Mission Type (Embassy, Consulate, UN, OAS, Other)

Address (Number, Street, Apt., City, State, Zip Code)

FOR OFFICE USE ONLY
Do not write in this space
License Tag

Principal Driver Name (Last, First, MI)

#:

I.D. Number

(Fee):
Principal Driver Name (Last, First, MI)

(C):

I.D. Number

(D):
Status of Principal User (Check One)

(2#):

Administrative/
Service Staff
Employee
Technical
Address Where Vehicle Is Principally Garaged (Number, Street, City, State, Zip Code)
Diplomatic

Consular

Dependent

I.D. Number
Vehicle Identification Number

Make

Model

O:
PD:

Body

Year

Weight

Odometer

PU
A:

Lien Holder/Legal Owner (Name in Full) If the registered owner is the legal owner write NONE.

Address
(Lien)
Insurance Company Name

LH:
T#:

Address

D:
LR:

Broker/Agent Name

Insurance

Address

C:
Binder or Policy Number

Insurance Coverage

OR

Beginning Date (mm-dd-yyyy)
Bodily Injury/Person

A. P/A/P

Expiration Date (mm-dd-yyyy)
Bodily Injury/Accident
Property Damage/Accident

(Personal Injury and Property Damage Per
Accident)

B. Combined Single Limit -

THE UNDERSIGNED CERTIFIES THAT, IN ACCORDANCE WITH THE PROVISIONS OF TITLE 18 U.S. CODE, SECTION
1001, PROHIBITING THE MAKING OF FALSE STATEMENTS IN CONNECTION WITH ANY FEDERAL MATTER, THE
INFORMATION STATED HERE IS TRUE AND CORRECT. THE REQUIRED INSURANCE LIABILITY COVERAGE WILL BE
MAINTAINED FOR ALL DRIVERS OF THIS VEHICLE AT ALL TIMES.

SPECIAL NOTE: FAILURE TO MAINTAIN AN INSURANCE POLICY FOR
THIS VEHICLE WILL RESULT IN CANCELLATION OF REGISTRATION
AND RECALL OF THE OFFICIAL FEDERAL LICENSE PLATES.
(EMBASSY SEAL)

DS-100 (Formerly DSP-100)
xx-xxxx

Authorized Signature(s)

Date(s) (mm-dd-yyyy)

P/A/P
COM
SPLIT