MVR27C (8/91)
NORTH CAROLINA DIVISION OF MOTOR VEHICLES
1100 New Bern Avenue
Raleigh, North Carolina 27697-0001
APPLICATION FOR A COLLEGIATE INSIGNIA LICENSE PLATE
Remit a $25.00 check or money order with this application.
The $25.00 Collegiate fee is an annual fee due in addition to the regular annual license fee.
Circle One

Automobile
or
Private Small Truck



Home


Area Code-Telephone Number

Office


Area Code-Telephone Number
NAME (to agree with certificate of title)


First        Middle         Last




Address



City           State                ZIP
Current NC

Plate Number

Sticker Number


Vehicle Identification Number

Year                  Make   

Model                 Style
Special
Collegiate Plate Fund
TOTAL		 $10.00
$15.00
$25.00
Classification
Collegiate
Branch No.

 Agent

DMV VALIDATION

I HEREBY MAKE APPLICATION FOR A COLLEGIATE INSIGNIA LICENSE PLATE FOR:
WESTERN CAROLINA UNIVERSITY

Owner's Certification of Liability Insurance and Property Tax
I CERTIFY FOR THE MOTOR VEHICLE DESCRIBED ABOVE THAT:
  1. I have financial responsibility as required by law.

    Print or type full name of insurance company licensed In N.C.-not agency or group

    Policy number-If policy not issued, name of agency binding coverage

  2. I was not the legal owner of this vehicle on January 1st of the year of this application.
  3. I owe no delinquent county or municipal taxes on this vehicle.
  4. I was the legal owner of this vehicle on January 1st of the year of this application and the vehicle was listed for property taxes in_________County.

    Signature of Owner                                                Date of Certification