Form Reg0 169 - Authorization For Vehicle Services

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Authorization for
Affix Document Label Here
Vehicle Services
This information is being collected for the purposes of motor vehicle records in accordance with the Traffic Safety Act. Questions about the collection of this information can be
directed to the Freedom of Information and Protection of Privacy Coordinator for the Alberta Government, Box 3140, Edmonton, Alberta T5J 2G7 780-427-7013.
This form is not a replacement for proof of ownership
* NOTE: If more names/signatures are required, please use the back of form.
PART 1 - OWNER/LESSEE INFORMATION
I/We,
,
Print Name of Owner/Lessee/Registrant
Driver's Licence Number or MVID for Organization
and
,
Print Name of Owner/Lessee/Registrant
Driver's Licence Number or MVID for Organization
give consent to
,
Print Name of Authorized Person or Organization
Driver's Licence Number or MVID for Organization
to act on my behalf to process the following transaction for the vehicle/plate indicated in Part 2 and/or 3.
PART 2 - VEHICLE INFORMATION
Licence Plate Number (if applicable) Make
Model
Year
Vehicle Identification Number (VIN)
PART 3 - SERVICE TYPE REQUEST
to MVID
New Plate (First Time Registration)
Transfer Personalized Plate from MVID
Renew Registration
Modify registration (provide details below)
Plate Transfer
Plate Exchange
Duplicate Registration
Tab Replacement
Cancel Plate/Registration
Parking Placard (Application/
exchange/renew/cancel)
Personalized/Specialty Plate
Order/Reorder
PART 4 - REGISTRATION PARTICULARS
Register vehicle in my/our name(s)
Register the vehicle in the
OR
exactly as shown on proof of ownership
name(s) as shown below:
Driver's Licence Number
Driver's Licence Number
Print Individual/Organization Name
Print Individual/Organization Name
or MVID for Organization
or MVID for Organization
Driver's Licence Number
Driver's Licence Number
Print Individual/Organization Name
Print Individual/Organization Name
or MVID for Organization
or MVID for Organization
PART 5 - SIGNATURES
Signatures of ALL applicable owners/lessees/registrants are required.
Date
Signature of Owner/Lessee/Registrant
Date (
Signature of Joint Owner/Lessee/Registrant
(yyyy-mm-dd)
yyyy-mm-dd)
Date
Signature of Owner/Lessee/Registrant
Date (
Signature of Joint Owner/Lessee/Registrant
(yyyy-mm-dd)
yyyy-mm-dd)
New or used vehicles coming from another province or from another country may require further
documentation and/or inspections. Consult with any Alberta registry agent for more details.
REG0169 (2014/07)

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