Fillable Printable Homebound Customer Request Form
Fillable Printable Homebound Customer Request Form
Homebound Customer Request Form
NGSDLS-005-Application/Customer Request
Special Conditions Transaction
Rev. 4-27-2016
North Carolina Division of Motor Vehicles
Special Conditions Service Homebound
Customer Request
1. Are you rendered “Homebound” due to an illness?
Yes
No
2. Can you provide supporting Medical Documentation?
Yes
No
3. Do you consent to a home visit from a DMV representative?
Yes
No
4. Have you ever had an issuance from the North Carolina DMV?
Yes
No
5. Name: _________________________________________________________________
6. Date of Birth: ____________________________________________________________
7. Residence Address: _______________________________________________________
_______________________________________________________________________
8. County: ________________________________________________________________
9. Point of Contact: _________________________________________________________
10. Telephone Number: ______________________________________________________
11. Request received via: Phone __________ Email: __________
Please fax this application to NC DMV – Issuance Resolution Unit at (919) 861-3393. Once this is
received, you will receive a call from a customer service representative to confirm that you
meet the requirements.
