North Carolina Application For Enrollment / Change In Electronic Lien And Title System printable pdf download

North Carolina Application For Enrollment / Change In Electronic Lien And Title System

NORTH CAROLINA APPLICATION

FOR ENROLLMENT / CHANGE IN ELECTRONIC LIEN AND TITLE SYSTEM

Lender Information

Please enter lienholder specific information here.

Please Note: If you are a customer with multiple lienholder names, a separate form should be completed for each.

Name of Business:

FEIN:

Physical Address:

Mailing Address:

City:

State:

Zip:

Lienholder Authorized Representative

Full Name:

Title:

Email:

Telephone:

Fax Number:

Date:

Lender Administrator

Indicate below an individual who will act as the lender administrator. This person is responsible for adding additional

users, deleting existing users and controlling the access rights of the lender’s users.

Full Name:

Email:

Telephone:

We _____________________________ have chosen Dealer Support Services from the approved service provider list to

be our official service provider for the North Carolina Electronic Lien and Title program and furthermore grant them

permission to enroll us as their client.

Signature: ____________________________________________

Date: _______________

Return completed form to:

Dealer Support Services

5448 Apex Parkway • Apex • NC • 24502

Phone # (919)267-3183/800-848-8751 • Fax # 863-937-9739• Email:

North Carolina Application For Enrollment / Change In Electronic Lien And Title System