I being first duly sworn or affirmed depose and state 10 That my current occupation is That my current employer is That my current employers address is That I have been employed during the past ten ID: 898343
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1 DL-101 (Rev. 8/08) CUSTOMER NO.AFFIDAVIT
DL-101 (Rev. 8/08) CUSTOMER NO.AFFIDAVIT FOR NAME CHANGE I, ____________________________________________________________, being first duly sworn or affirmed, depose and state: 10. That my current occupation is______________________________________________________________________________ That my current employer is_______________________________________________________________________________ That my current employers address is_______________________________________________________________________ That I have been employed during the past ten years as follows: Employer______________________________________________________________________________________________ Employers address______________________________________________________________________________________ Date of employment from: __________________________________ to ___________________________________________ Employer______________________________________________________________________________________________ Employers address_________________________________________________________
2 _____________________________ Date of em
_____________________________ Date of employment from: __________________________________ to ___________________________________________ That the change of name request is not: a. For any fraudulent or wrongful purpose. b. Detrimental to the rights or interests of any other person(s). c. Prohibited by or violative of any judicial or administrative adjudication. 13. That I understand that is a violation of the Motor Vehicle Laws of North Carolina to use a false or fictitious name or address or to conceal a material fact in my application for a drivers license or ID card and that I may be punished as allowed by law. . I declare that the foregoing is true and correct. Signature:_____________________________________________________________________date ______/______/________ State:__________________________________________ County________________________________________________ X________________________________________________ (Notary Public) State:_________________________________________________ Commission Expires:____________________________________