Auto Lien Source

Your Business Information
Business Name
Contact Person
Physical Address
Mailing Address
County
Phone
Fax
Vehicle Information
Make
Model
Plate
State
VIN
Service Information
Service Date
Service Amount
Daily Storage Rate
Appraised Value
Required 		$0 - $999
$1000 - $2499
$2500 < Over
Requested By
Required 		Police
PPI
Owner
Owner/Customer
(Please fill in owner information below)
Name
Address
City
State
Zip
Reference #
Comments
Authorization
Required
I authorize Auto Lien Source to Act on my behalf to obtain information and to give notice concerning a lien vehicle.

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 box constitutes a digital signature, and must be checked to process this Lien Service Order.
  

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Auto Lien Source is an Oregon Bonded and Insured Company

Owners: Greg and Karen