MVR-27SC Rev 7/18 Division of Motor Vehicles 3155 Mail Service Center Raleigh, NC 27697-3155

APPLICATION FOR A THEME LICENSE PLATE

 Regular Stock Car Racing Theme $30.00  Personalized Stock Car Racing Theme $60.00 When applying for a personalized Stock Car Racing Theme license plate, please remember the suffix representing the driver will be the last letters on the plate. Personalized special plate choice must contain at least one alpha character. Please remember the suffix that follows the driver’s name. You are allowed four (4) spaces for a personalized message ______

Note: Personalized spaces can be letters only or a combination of letters, numbers, and special characters. Numbers only are not permitted. I would like to make application for the following license plate:

(Suffix RC)  #18 (Suffix BH)  #14 (Suffix CB)  #78 Martin Truex (Suffix TX)  Hall of Fame (Suffix DE)  #20 (Suffix NK)  #88 Dale Earnhardt, Jr. (Suffix JR)  NASCAR (Suffix NR)  #10 (Suffix DP)  NASCAR Ford Racing (Suffix FR)  #11 (Suffix DH)  NASCAR Hall of Fame (Suffix HF)  #48 (Suffix JJ)  NASCAR Race Fan (Suffix RF)  #5 (Suffix KK)  Historic (Suffix RP)  #4 (Suffix KH)  #17 Ricky Stenhouse Jr. (Suffix SH)  #41 (Suffix KB)  #6 (Suffix TB)

The $30.00/$60.00 special fee is an ANNUAL fee due in addition to the regular license fee.

NAME (As listed on certificate of Title): CONTACT INFORMATION:

HOME PHONE: ______FIRST MIDDLE LAST OFFICE PHONE: ______

CELL PHONE: ______ADDRESS VEHICLE INFORMATION:

CITY STATE ZIP CODE

VEHICLE IDENTIFICATION NUMBER

DRIVER LICENSE # STATE CURRENT NC PLATE YEAR MAKE BODY STYLE NUMBER

Owner’s Certification of 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