Fillable Printable Application For A Ducks Unlimited License Plate

Application For A Ducks Unlimited License Plate

North Carolina Division of Motor Vehicles

3155 Mail Service Center

Raleigh, North Carolina 27697-3155

APPLICATION FOR A DUCKS UNLIMITED LICENSE PLATE

Remit a $20.00/$50.00 check or money order with this application.

q Regular Ducks Unlimited $20.00 qPersonalized Ducks Unlimited $50.00

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

The $20.00/$50.00 special fee is an (ANNUAL) fee due in addition to the regular license fee.

NAME (To agree with certificate of title)

FIRST MIDDLE LAST

ADDRESS

CITY STATE ZIP CODE

Current North Carolina

PLATE NUMBER VEHICLE IDENTIFICATION NUMBER

DRIVER LICENSE # YEAR MODEL MAKE BODY STYLE

MVR-27DU

(Rev. 9/17)

Home

AREA CODE–TELEPHONE NUMBER

Office

AREA CODE–TELEPHONE NUMBER

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