(Rev. 09/12)
be issued. If the vehicle is owned by a nonresident and is registered in a state other than North Carolina, the certificate
CHECK Appropriate Block/s (Application cannot be processed without certification of services)
Limited Registration Plate Truck Weight Desired ________________________________
Yes or No
For Hire Vehicle Plate No. Transferred _________________________________
Yes or No (List Plate Number and Expiration)
I certify that all the above information is correct. ___________ (Customer’s Initials)
VEHICLE SECTION
YEAR MAKE BODY STYLE SERIES MODEL
VEHICLE IDENTIFICATION NUMBER TYPE OF FUEL ODOMETER READING ODOMETER BRAND
NAME OF OWNER (Lessor) STATE IN WHICH VEHICLE REGISTERED TERM OF LEASE
DISCLOSURE SECTION
All motor vehicle records maintained by the North Carolina Division of Motor Vehicles will remain closed for marketing and solicitation unless
the block below is checked.
I (We) would like the personal information contained in this application to be available for disclosure.
LESSEE SECTION
Lessee 1 ID # _________________________ ______________________________________________________________________________
Full Legal Name of Lessee 1 (First, Middle, Last, Suffix) or Company Name
Lessee 2 ID # _________________________ ______________________________________________________________________________
Full Legal Name of Lessee 2 (First, Middle, Last, Suffix) or Company Name
Residence Address (Individual) Business Address (Firm) City and State Zip Code
Mail Address (if different from above) City and State Zip Code
Vehicle Location Address (if different from residence address above) City and State Zip Code Tax County
I, (We) certify that the described vehicle is leased from the owner and that this vehicle is to be used by me and that the information on the
application is correct to the best of my (our) knowledge. I further certify the above listed vehicle is properly insured as required under G.S. 20-
309 by:
_____________________________________________________ _____________________________________________________
Insurance Company Authorized in N.C. Policy Number
Signature of lessee ____________________________________________________________________________________________________
(Must be personally signed in ink by the lessee; if firm or corporation, by one of its authorized representatives, or, if in joint ownership, signature by each must be affixed)
LESSOR CERTIFICATION SECTION
As owner of the above described motor vehicle, I do certify that it has been leased to the person, firm or corporation whose name
appears as lessee and further certify that it is being used by such lessee. Consent for the licensing of this vehicle in the name of the
lessee is hereby given. The vehicle is properly insured, by the company listed above, as required by G.S. 20-309.
Signature of lessor __________________________________________________________________________________________________________________
(Must be personally signed in ink by the lessor; if firm or corporation, by one of its authorized representatives, or, if in joint ownership, signature by each must be affixed)
