Tow Company Submission Form

    1: Vehicle Information

    Year*


    Make*


    Model*

    Plate*


    State*


    VIN*

    Service Date*


    Service amount (not including storage)*


    Daily Storage Rate*

    Appraised Value*


    Appraised Value (Verified)*

    Type of Tow*
    Additional information about the vehicle

    Business Information

    Company Name


    First Name*


    Last Name*

    Physical Address

    Street Address*


    City*

    State*


    Zip*


    County*

    Mailing Address

    Street Address*


    City*

    State*


    Zip*


    County*

    Phone and Email

    Your Email *


    Phone*


    FAX

    AUTHORIZATION: I authorize Oregon Lien Source to Act on my behalf to obtain information and to give notice concerning a vehicle(s).

    - By checking this box, you hereby agree to the terms stated in the 'AUTHORIZATION' section above and confirm that the information provided on this form is accurate and truthful to the best of your ability. This checkbox constitutes a digital signature, and must be checked to process this Lien Service Order.*

    I agree to the terms

    3: Vehicle Owner Information

    (only required if vehicle owner requested tow)

    Owner's First Name


    Owner's Last Name

    Owner's Street Address


    Owner's City


    Owner's State


    Owner's Zip

    4: Verification and Submission

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