Fillable Printable Application For A Scuba License Plate

Application For A Scuba License Plate

MVR-27DI

(Revised9/17)

North Ca

rolina Division ofMotor Vehicles

3155Mail Service Center

Raleigh, NC27697-3155

APPLICATION FOR ASCUBALICENSE PLATE

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

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First in Flight Background

First in Freedom Background

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Regular Scuba$20.00

Personalized Scuba$50.00

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

When applying for a Personalized Scubalicense plate, the suffix DIwill be the lastletters on the plate. This leaves only four (4) spaces

for a Personalized message. The four spaces may be a combination of letters and numbers, b ut cannot be numbers only. Choicecannot

conflict with another class of license plates.

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

Home

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AR EA CO DE-T ELEP HONE NUM BER

Office

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AR EA CO DE-T ELEP HONE NUM BER

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 Certification of Liability Insurance

I CERTIFY FOR THE M OTOR VEHICLE DESCR IBED ABOVE THAT I HAVE FINANCIAL RESPONS IBILITY AS REQUIRE D BY LAW.

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

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

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SIGNATURE OF OWNER DATE OF CERTIFICATION