MVR-27PP-A (11/15)

North Carolina Botanical Garden Foundation, Inc. c/o North Carolina Botanical Garden CB 3375, Chapel Hill, NC 27599 919-962-0522

Application for a HOME OF THE VENUS FLYTRAP License Plate To apply, print and complete this form and mail to the address above along with a $30.00/$60.00 check or money order made payable to the North Carolina Botanical Garden Foundation. Please note: The $30.00/$60.00 fee is an (ANNUAL) fee due in addition to the regular license fee.

Regular Home of the Venus Flytrap $30.00 Personalized Home of the Venus Flytrap $60.00

You are allowed four (4) spaces for a personalized plate. Indicate your selection. ____ ____ ____ ____

Indicate 2nd option if 1st selection not available. ____ ____ ____ ____

NAME (to agree with certificate of title):

FIRST MIDDLE LAST ADDRESS: CITY, STATE and ZIP CODE:

HOME PHONE: ( ) - WORK PHONE: ( ) - Current North Carolina

PLATE NUMBER DRIVER LICENSE NUMBER

Vehicle Information YEAR MODEL MAKE BODY STYLE VEHICLE IDENTIFICATION NUMBER

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 SIGNATURE OF OWNER DATE OF CERTIFICATION