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Fillable Printable Application For A Coastal Land Trust License Plate

Fillable Printable Application For A Coastal Land Trust License Plate

Application For A Coastal Land Trust License Plate

Application For A Coastal Land Trust License Plate

MVR-27 CT
(Rev. 09/17)
APPLICATION FOR A
COASTAL LAND TRUST
LICENSE PLATE
Remit a $30.00/$60.00 check or money order with this application.
Regular COASTAL LAND TRUST $30.00
Personalized COASTAL LAND TRUST $60.00
NOTE: You are allowed four (4) spaces for a personalized message. ___ ___ ___ ___
When applying for a Personalized Coastal Land Trust license plate, the suffix CT 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 another class of license plates.
The $30.00/$60.00 special fee is an (ANNUAL) fee due in addition to the regular license fee.
Home
_______________________
AREA CODE-TELEPHONE NUMBER
Office
______________________
AREA CODE-TELEPHONE NUMBER
NAME (To agree with certificate of title)
________________________________________________________________
FIRST MIDDLE LAST
________
___________________________ _____________________________
ADDRESS
________
___________________________ _____________________________
CITY STATE ZIP CODE
Current North Carolina
__________________
Plate Number
_________________
Driver License #
_______
____________________________ ______
Vehicle Identification Number
_____________________________ ____________
Year Model Make Body Style
Owner’s Certification of Liability Insurance
I CERTIFY FOR THE MOTOR VEHICLE DESCRIBED ABOVE THAT I HAVE FINANCIAL RESPONSIBILITY AS REQUIRED BY LAW.
_____________________________________________________________________________________________________________________________________
PRINT OR TYPE FULL NAME OF INSURANCE COMPANY AUTHORIZED IN N.C. – NOT AGENCY OR GROUP
______________________________________________________________________________________________________________________________________
POLICY NUMBER – IF POLICY NOT ISSUED, NAME OF AGENCY BINDING COVERAGE
_____________ _______________ _______________ _________ _____________________________________________
SIGNATURE OF OWNER DATE OF CERTIFICATION
North Carolina Division of Motor Vehicles
3155 Mail Service Center
Raleigh, North Carolina 27697-3155
C
T
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