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<br /> tZ Dep a titecnt of t onsuinei'and Business Service.
<br /> 1535 Edgewater St:NW,Salem;Oregon.,Phone: 501-378,4530 •Ea. 03-3784101.
<br /> Web oregon;gvv/be4 Email: itilio.ds,bcd4otegan:gov
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<br /> This application Must.be sttiiinitted Wvithtt.Valid taax;.0ertif'icatirn1r.om•tIte e:e<tnty in:wlu;;li.the hOi is currently located:,:
<br /> as Lvell as the count tire.hon c<is moving to...A valid.tax certi kation;is oile_tnat.has bee.n.certi led by the wipity drier
<br /> . .subiiiittcd before the expiration date provided by tl e.c linty'at•(lietxirtoof`eei•tifcca i�ii;
<br /> a ROOXI T 1 FOR AT1 3P�
<br /> Manic ',- `' !� i,` .
<br /> Aodic,s:(including city,state,.and 71.P):_ t..t<cl t , `; ��?pt '.• Vic'-. ._ .: t`t�h 1 t. .c.....42, :•1.1 j__1
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<br /> • j Adds ess(incluiii,g c..tt ,state,a:nd 7JP):, J-z;-t,l4, ' ;' t�-t (:).:(2,, - '--1-7/4-43 -- .
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<br /> .:l Email; . . . • . . . • .
<br /> .----_. _. ....SOME INFORMAT O t
<br /> :Home Ili,Ii:i mmtiei-(rf knou nt•' . - . DMV h phte nimrnbcr(it kncoi±n)
<br /> vlanuifhctaiet `' t l.� )Ne., •lvioci&t i Year .4:L i °'f
<br /> I°II_ID label •numbers: °:,
<br /> Serial.numbers:::. ' f c�� --:n.1.4.‘7.2.,,. _
<br /> ►[DD .ESSS I F+CORM ATIOiV ;:-
<br /> ( utiet t toe trioti tinclutho city,stae,/1P) s : `�J i : .- ,:Sid Er t t : .) .1 Cotnt5:'` rkiti "t11
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<br /> .Manuiactined.lioire nail namie,if alpp€icablc: ...
<br /> D Oregon dealer lot• I Dealer name • . . . . . . . . .
<br /> D Oi't oi- tato dealer, U,.afci name a=td contact i+ifoi matior JI t.. 'j . ':21.55• tai- i
<br /> •• Placement location ttncludrna city state,/IP) t.-.1 c5 • ;, ,. c j •` : t € CtoiInty .., •::10:-1'1:L': ;
<br /> • Manttfai tai cd.homc .aik.nanle.11 a livable;ti \�Y ; ear��._.. . • • F i 3.0 t
<br /> [p Oregon deakei°lot . De iter iiiciiia '\m.`A:i i , ,yA.k'-;, • 1.—: ,..-‘,.......-,-. .•,..• . ..
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<br /> nt sig 7atttre .:( �:. .. �-, ,t ~�
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<br /> &.tt.p per it(Per satin). .. ',35:.411•(70511:...',119.5). S:47- , . .
<br /> Mute cheek or nir.mey order payable too'Departinent of Conisinner:and i3usiness•Services.If paying by eretiat.carcl,applicant
<br /> must siiio.Cl edit::0rd iiforniatiun.box.Do nut.send cash.ken;re Jav .503-947 2333
<br /> 31V np D is''as rci t ❑':)iscover iliveel.i i . 1 1
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<br /> . . 1,1timw of cagl.€wider as.shown,on c:
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