Form Mvr-49 - Fire Department Or Rescue Squad printable pdf download

NORTH CAROLINA DIVISION OF MOTOR VEHICLES

MVR-49

(Rev. 9/17)

3155 Mail Service Center

Raleigh, North Carolina 27697-3155

APPLICATION FOR A SPECIAL REGISTRATION PLATE

FOR A MEMBER OF A FIRE DEPARTMENT AND/OR A RESCUE SQUAD

(Fee $10.00/$40.00 – Remit check or money order with application)

The $10.00/$40.00 special fee is an annual fee due in addition to the regular fee.

NOTE: You are allowed four (4) spaces for a personalized message.

Personalized Fire Department V ___ ___ ____ ___

Personalized Rescue Squad R ___ ___ ____ ___

Personalized Fire Rescue Squad R ___ ___ ____ ___

Office Telephone____________________________

Name ______________________________________________________

Home Telephone____________________________

(TO AGREE WITH CERTIFICATE OF TITLE)

Residence Address

______________________________________________________________________________________

City ____________________________ State __________ Zip Code______________ County ________________________

I, the undersigned, do hereby certify that I am a member of a Fire Department q or Rescue Squad q

or both q and that I am entitled to this special registration plate as provided for under G.S. 20-79.4.

Year model ____________ Make __________________________________ Body style ______________________________

Vehicle identification number ________________________________ Title number ______________________________

Current plate number __________________________

____________________________________________________

SIGNATURE OF OWNER

TO BE COMPLETED BY THE FIRE DEPARTMENT CHIEF AND/OR THE RESCUE SQUAD CHIEF

This will certify that the above named individual is a member of a Fire Department or a Rescue Squad, or

both, and is entitled to receive one of these special registration plates.

____________________________________________________

Address __________________________________________

SIGNATURE OF CHIEF

____________________________________________________

Date ______________________

FIRE DEPARTMENT

RESCUE SQUAD

BOTH

Owner’s Certification of Liability 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

INSTRUCTIONS FOR OBTAINING SPECIAL REGISTRATION PLATES

FOR MEMBERS OF FIRE DEPARTMENTS AND/OR RESCUE SQUADS

1. The issuance of special registration plates to members of fire departments and members of rescue squads is restricted to private

passenger motor vehicles or pickup trucks not exceeding a gross weight of 26,000 pounds.

2. These special registration plates are restricted to active regular or volunteer members of a fire department or a rescue squad or both.

3. This application must be filed with the Division of Motor Vehicles, Raleigh, N.C. 27697-0001 on a form approved by the Division.

4. The fee for this special registration plate is $10.00 annually and is in addition to the regular registration plate fee. A check or

money order in the amount of $10.00, payable to the Division of Motor Vehicles, must accompany this application.

5. This application must be signed by the chief of a fire department or a rescue squad who is certifying that the applicant is an active

regular or volunteer member of a fire department or rescue squad or both.

6. The vehicle for which the special registration plate will be issued must be registered in the name of the applicant, or jointly, so long

as the applicant is co-owner of said vehicle.

Form Mvr-49 - Fire Department Or Rescue Squad

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