Vehicle Registration – Safe Insurance Brokers

VEHICLE REGISTRATION FORM

PLEASE PRINT IN BOLD LETTERS

REGISTRATION TYPE

REGISTRATION CATEGORY

USAGE

PLATE NUMBER

TIN

CURRENCY

DATE

OWNER'S NAME

ADDRESS

DISTRICT

COUNTY

PHONE

PREVIOUS OWNER

PLATE #

ISSUE DATE

VIN NUMBER

MANUFACTURE YEAR

MAKE

MODEL

PURCHASE DATE

STATEMENT OF DECLATION

I THE UNDERSIGNED, DO HERE BY CONFIRM THAT THE INFORMATION PROVIDED BY ME IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. IF ANY OF THE INFORMATION IS FOUND TO BE INCORRECT, I WILL BE HELD LIABLE FOR SUCH INCORRECT INFORMATION OF SAID VEHICLE CERTIFICATE.

VEHICLE REGISTRATION FORM

PLEASE PRINT IN BOLD LETTERS

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