CHECK Appropriate Block/s (Application cannot be processed without certification of services)
Title Only – Vehicle Not in Operation Truck Weight Desired ________________________ For Hire Vehicle
(This includes the truck, trailer and load) Yes or No
Title and License Plate Plate No. Transferred ________________________________
Class of License __________________ (List Plate Number and Expiration)
Inoperable Vehicle – Vehicle substantially disassembled Limited Registration Plate
and unfit or unsafe to be operated on the highway (When property taxes are deferred)
I certify that all the above information is correct. ___________ (Customer’s Initials)
VEHICLE SECTION
YEAR MAKE BODY STYLE SERIES MODEL VEHICLE IDENTIFICATION NUMBER FUEL TYPE ODOMETER READING
OWNER SECTION
Owner 1 ID # _____________________ ______________________________________________________________________________________________________________________________________________________
Full Legal Name of Owner 1 (First, Middle, Last, Suffix) or Company Name
Owner 2 ID # _____________________ ______________________________________________________________________________________________________________________________________________________
Full Legal Name of Owner 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
LIEN SECTION
Lienholder ID # Lienholder Name Lienholder ID # Lienholder Name
Address ______________________________________________________ __________ Address ____________________________________________________________________
City ______________________ State _________ Zip Code ______________________ City _______________________________ State ________ Zip Code __________________
I certify for the motor vehicle described above that I have financial responsibility as required by law.
___________________________________________________________ _________________________________________________________
Insurance Company authorized in N.C. Policy Number
Purchased Purchase Date From Whom Purchased (Name and Address) N.C. Dealer No. Is this vehicle leased? Equipment #
If Yes, Attach Form MVR-330
New Used Yes No
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.
APPLICATION MUST BE SIGNED IN INK BY EACH OWNER OR AUTHORIZED REPRESENTATIVE OF FIRMS OR CORPORATIONS.
I (we) am (are) the owner(s) of the vehicle described on this application and request that a North Carolina Certificate of Title be issued. I (we) certify that the information on
the application is correct to the best of my (our) knowledge. The vehicle is subject to the liens named and no others. If a registration plate is issued or transferred, I (we)
further certify that there has not been a registration plate revocation and that liability insurance is in effect on this vehicle on the date of this application as required by the
North Carolina Financial Security Act of 1957.
OWNER’S SIGNATURE ______________________________________________________________________________________________________________________
Date ________________________________ County _______________________________________ State ____________________________________
I certify that the following person(s) personally appeared before me this day, each acknowledging to me that he or she voluntarily signed the foregoing document for the
purpose stated therein and in the capacity indicated: _________________________________________________________________________(name(s) of principal(s) ).
Notary Notary Printed
Signature _____________________________________________________ or Typed Name ______________________________________________________
(SEAL) My Commission Expires _______________________________________________
(Rev. 05/17)
