Fillable Printable Alpha Kappa Alpha

Alpha Kappa Alpha

MVR-27KA

(Revised 9/17)

North Carolina Division of Mot or Ve

hicles

3155 Mail Service Center

Raleigh, NC 27697-3155

APPLICATION FOR AN

ALPH A KAPPA ALPH A

LICENS E P

LATE

Remit a $10.00/$40.00 check or money order with this application.

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First in Flight Background

 First in Freedom Background

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Regular Alpha Kappa Alpha $10.00

 Personalized Alpha Kappa Alpha $40.00

NOTE: You are allowed four (4) spaces for a personalized message.

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When applying for a Personalized Alpha Kappa Alpha license plate, the suffix KA will be the last letters on the plate. This leaves only

four (4) spaces for a Personalized message. The four spaces may be a combination of letters and numbers, but cannot be numbers only.

Choice cannot conflict with a nother class of license plates.

The $10.00/$40.00 special fee is an ( ANNUAL) fee due in addition to the regular license fee.

Home

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AR EA CODE-TE LE PHON E N U MBER

Office

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AR EA CODE-TE LE PHON E N U MBER

NAME (To agree with certificate of title)

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FIRST MIDDLE LAST

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ADDRESS

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CITY STATE ZIP CODE

Current North Carolina

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Plate Number

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Driver License #

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Vehicle Identifica tion Number

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Year Model Make Body Style

Owner’s Certifica tion of Liability Insura nce

I CERTIFY FOR THE M OTOR VEHICLE DESCRIBED ABOVE THAT I HAVE FINANCIAL RESPONSIBILITY AS RE QUIRED BY LAW.

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PRINT OR TYPE FULL NAME OF INSURANCE COM PANY AUTHOR IZED IN N.C. – NOT AGENCY OR GROUP

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POLICY NUMBER – IF POLICY NOT ISSUED, N AME OF AGENCY BINDING COVER AGE

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SIGNATURE OF OWNER DATE OF CERTIFICATION