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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