Wrecker Owner License

Wrecker Owner LicenseWMMG Admin2021-06-14T10:06:39-04:00

Town of Mocksville

Kenneth W. Gamble, Town Manager / 171 S. Clement Street / Phone – 336-753-6701 / Fax – 336-751-9187

Application for Wrecker – Owner License

Wrecker Owner License Application

Name of Individual Owner*

First

Last
Phone
Address*
Street Address Address Line 2 City State ZIP Code
Years/Months Resided at Current Residence*
Previous Address
Street Address Address Line 2 City State ZIP Code
List Other Previous Addresses Here:
Date of Birth*

Month

Day

Year
Social Security Number*
Driver's License #*
Where were you born?*
Are you a citizen of the United States?*
- Yes
- No
If Naturalized:
Please provide the date, number, and location of the court where you were naturalized.
Have you ever been arrested or summoned to Court?*
- Yes
- No
If yes, give particulars and dispositions of every case:
List any other cases here:
If Co-Partnership Exists – Firm Name
Company's Main Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
List any other branch office locations here:

Company Name Company Branch Location
Address where all towed vehicles are to be kept:*
Street Address Address Line 2 City State ZIP Code
Are you the owner or lessee of wrecker?*
- Yes
- No
Are you a member of any main company or any co-operative or operating association?*
- Yes
- No
If you are, what is the name of same?
Is your business covered by insurance as required by North Carolina State Law?*
- Yes
- No
Name of Insurance Company:*
Policy #*
Date of Insurance Expiration:*

Month

Day

Year
Consent*
By checking the consent box and signing below I attest that the answers to the foregoing questions and other statements contained therein are true to the best of my knowledge and belief. I also agree and consent to a criminal history background check to be completed by the Davie County Sheriff’s Office.

I consent to a background check.
Signature*
You may sign virtually using a mouse, stylus, or touchpad.

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