Application For Registration, Renewal, Replacement Or Transfer Of Plates And/or Stickers
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REMARKS:
Application for Registration,
DMV
Renewal, Replacement
REG / REN FEE
or Transfer of Plates
DEPARTMENT OF TRANSPORTATION
DRIVER AND MOTOR VEHICLE SERVICES
and/or Stickers
1905 LANA AVE NE, SALEM OREGON 97314
REPLACEMENT FEE
PLATE CODE
MP
EX
MISC
HVUT
PERMIT #
TRANS CODE
VT
NEW PLATE #
STICKER #
VEHICLE IDENTIFICATION NUMBER (VIN)
OREGON TITLE #
PLATE TRANSFER FEE
1
EXPIRATION DATE
PRESENT OREGON PLATE #
YEAR
STYLE
WEIGHT / LENGTH
MAKE
EQUIPMENT #
2
TOTAL FEE PAID
SPECIAL PLATES
FARM ID #
FLEET ACCOUNT #
DIESEL
HYBRID
GAS
3
ELECTRIC
PROPANE
OTHER:
This application cannot be used to change or correct the name(s) shown on the title or to change ownership.
Complete Line 4 with the owner whose address will be used for all DMV mail regarding this vehicle. List additional owners on Lines 7
and 8. (This in no way determines a priority of ownership.) If any owner listed uses an agency address on DMV records, that
owner must be shown on Line 4. See reverse for more information.
LAST, FIRST, MIDDLE OF (check one)
ODL / ID / CUSTOMER #
DATE OF BIRTH
OWNER
OR
LESSEE
4
RESIDENCE / BUSINESS ADDRESS - (Address will be used to update your ODL / ID Card)
MAILING ADDRESS - (If different from residence)
5
CITY, STATE, ZIP CODE
COUNTY OF RESIDENCE
CITY, STATE, ZIP CODE
COUNTY OF MAILING
6
LAST, FIRST, MIDDLE (See “Change of Address” on reverse)
ODL / ID / CUSTOMER #
DATE OF BIRTH
7
ODL / ID / CUSTOMER #
DATE OF BIRTH
LAST, FIRST, MIDDLE (See “Change of Address” on reverse)
8
ONE-TIME MAILING ADDRESS (For this transaction only – address will not show on your customer record)
VEHICLE ADDRESS - (Location of vehicle if different from residence)
9
CITY, STATE, ZIP CODE
COUNTY (of vehicle address or use)
CITY, STATE, ZIP CODE
10
By signing this application, I certify that:
1) If this application includes registration, and this motor vehicle is subject to the financial responsibility laws, I am in compliance and will
remain in compliance until the vehicle is transferred; or 2) If this application includes a registration renewal, this vehicle is covered by the
motor vehicle liability insurance policy listed below.
INSURANCE COMPANY (not agent)
POLICY #
11
My home is in Oregon or I am otherwise eligible or required to register this vehicle under Oregon law. (Proof may be required if the department
has reason to believe you are not domiciled in Oregon. ORS 803.200, ORS 803.350, ORS 803.360).
If the vehicle is registered as tow/recovery, farm, manufactured structure toter, or charitable/non-profit, the vehicle still qualifies for special
registration and the use still conforms to the law as previously certified.
If this is a commercial vehicle, I am knowledgeable of the applicable federal motor carrier safety regulations and hazardous materials
regulations or compatible state regulations.
If I am a company required by federal law to participate in a drug and alcohol testing program, then I certify that I have an in-house program
that meets federal requirements, or that I am a member of a consortium that provides testing that meets federal requirements, or that I am
exempt from this requirement by federal law.
THE NAME(s) OF PERSON(s) OPERATING THE CONSORTIUM
The information provided on the front and back of this application is true and correct to the best of my knowledge. I understand it is a crime
under ORS 803.375, to certify the truth of a statement when I know the statement is not true. This offense is a Class A misdemeanor and is
punishable by a jail sentence of up to one year, a fine of up to $6,250, or both.
SIGNATURE OF OWNER AS SHOWN ABOVE
DATE
TELEPHONE #
12
X
HOME:
WORK:
SIGNATURE OF JOINT OWNER AS SHOWN ABOVE
DATE
COUNTER DATE STAMP / INITIALS
13
X
Transaction Type:
Plate Type:
Disposition of Plates:
14
LOST
REGISTRATION / RENEWAL
GROUP
CUSTOM
CRATER LAKE
SURRENDERED
REPLACE PLATE(S)
STOLEN
TREE
SALMON
CULTURAL
MUTILATED
REPLACE STICKER(S)
OTHER: _______________________________
REPLACE REG. CARD
REMARKS:
735-268 (
)
STK# 300111
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