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INV. 26-15

AUTOMOBILE INSPECTION UNIT, INVESTIGATIONS DIVISION

Rev. 7/89

P. O. Box 327641, Montgomery, Alabama 36132-7641

APPLICATION FOR INSPECTION OF A SALVAGE VEHICLE AND AFFIRMATION SUPPORTING SALVAGE CERTIFICATE

OWNER INFORMATION

REBUILDER'S LICENSE #_______________________

RESIDENT ADDRESS IF DIFFERENT

__________________________________________________

NAME___________________________________________________

__________________________________________________

MAILING ADDRESS________________________________________________

PHONE (HOME)_______________(WORK)______________

CITY_______________________STATE_______ZIP______________

PHYSICAL LOCATION OF VEHICLE FOR INSPECTION PURPOSES

LIENHLDER INFORMATION

(DO NOT LIST ROUTE ADDRESSES)

NAME_______________________________LIEN DATE_____________

______________________________________________

STREET ADDRESS__________________________________________

______________________________________________

CITY____________________STATE______ZIP_______

COUNTY:

LIST ALL ADDITIONAL LIENS ON A SEPARATE SHEET AND ATTACH

The undersigned hereby affirms to be the owner(s) of the following described vehicle which was acquied on __________________________________________________

(Date)

_______________________________________________________________________________________________________

VEHICLE IDENTIFICATION NUMBER

MAKE

YEAR

MODEL

BODY TYPE

ODOMETER READING

_______________________________________________________________________________________________________

PREVIOUS TITLE NUMBE

TITLE STATE

CYLINDERS

NEW

USED

DATE OF PURCHASE

NO. LIENS

COLOR

Applicant hereby makes application for inspection of the above described vehicle which has been completely restored by applicant in this state(ALABAMA) to its operating condition

which existed prior to the event which caused the attached salvae certificate of title, permit to dismantle, total loss certificate, or similar tupe certificate to issue. Applicant further staes

that no parts listed below have been changed, or if any of the parts listed below have been changed, same are listed. Notarized bills of sale of major component parts and

transmission (listing the manufacturer's vehicle identification number of the vehicle from which the parts were removed) must accompany this application. Bills of sale must be

provided for minor component parts.

COMPONENT PARTS (AS DEFINED IN ACT 89-863 ALABAMA LEGISLATURE REGULAR SESSION)

MAJOR COMPONENT PARTS REPLACED

GENERAL

VIN

YEAR

MAKE

ACQUIRED FROM

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

1. [ ] Motor or Engine

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

$0.00

2. [ ] Cowl, firewall or any portion thereof

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

3. [ ] Roof assembly

SPECIFIC:

PASSENGER VEHICLES

1. [ ] Trunk floor pan or rear section &

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

roof

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

2. [ ] Frame or any portion thereof,

(except frame horn), or, in the

case of a unitized bode, the

supporting structure which

serves as the frame, except

when it is a part of the trunk

floor pan, or rear section and roof

TRUCK, TRUCK TYPE OR BUS TYPE

VEHICLES

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

1. [ ] Frame or any portion thereof

(except frame horn), or in the case

of a unitized body the supporting

structure which serves as the frame

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

2. [ ] Cab

3. [ ] Cargo compartment floor panel or

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

passenger compartment floor pan

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

4. [ ]

Transmission or trans-axle

MINOR COMPONENT PARTS REPLACED

1. [ ]

Transmission (Passenger vehicle

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

only)

2. [ ] [ ] Each left door allowing entrance to or egress from the

13. [ ]

Left front fender (Truck, truck type, bus only)

passenger compartment

14. [ ]

Right fender (Truck, truck type, bus only)

3. [ ] [ ] Each right door allowing entrance to or egress from the

15. [ ]

Roof panel and rear cab panel(Truck, truck type, bus only

passenger compartment

16. [ ]

Left rear fender or left side panel (Truck, truck type, bus only)

4. [ ]

Hood

17. [ ]

Right rear fender or right side panel (Truck, truck type, bus only)

5. [ ]

Front bumper

18. [ ]

Grill, except on one tone or smaller trucke. (Truck, truck type

6. [ ]

Rear bumper

bus only)

7. [ ]

Left front fender or left rear fender when used with a rear

19. [ ]

Pick up box. (Truck, truck tpe, bus only)

section and roof (Passenger vehicle only)

20. [ ]

Body or bed. (Truck, truck type, bus only)

8. [ ]

Right front fender or right rear fender when used with a

rear section and roof. (Passenger vehicle only)

ALL MINOR COMPONENT PARTS BEARING FULL OR PARTIAL VEHICLE

9. [ ]

Left quarter panel. (Passenger vehcile only)

IDENTIFICATION NUMBERS SHOULD BE LISTED BELOW:

________________________________________

10. [ ]

Right wuarter panel. (Passenger vehicle only)

________________________________________

11. [ ]

Deck lid, tailgate or hatchback (whichever is present)(Passenger vehicle only)

12. [ ]

T-Tops, moor roof, or whichever is present (Passenger vehicle only)

MOTOR CYCLES

VIN

MAKE

ACQUIRED FROM

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

1. [ ]

Engine or motor

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

2. [ ]

Transmission or trans-axle

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

3. [ ]

Frame.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

4. [ ]

Front fork.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

________ ________ ______________________

5. [ ]

Crankcase.

___________________________________________________________________________

Other parts replaced/repaired

APPLICANT FURTHER STATES THAT THE FOLLOWING WAS DONE TO RESTORE SAID VEHICLE TO ITS OPERATING CONDITION WHICH EXISTED PRIOR TO THE

EVENT WHICH CAUSED THE ATTACHED SALVAGE CERTIFICATE, PERMIT TO DISMANTLE, TOTAL LOSS CERTIFICATE, OR SINILAR TYPE CERTIFICATE TO ISSUE:

(PAINTING, REPLACE GLASS, ETC.)

____________________________________________________________________________________________________________________________________ List the original

_ _ _ _ _ _ _ _ _ _ _

manufacturer's public vehicle identification number

_ _ _ _ _ _

Said plate [ ] (DOES) or [ ] (DOES NOT) remain properly attached in its original location on the vehicle and that said plate and number [ ] ( HAS) or [ ] (HAS NOT) been altered

mutilated in any way. Applicant further states that (1) Applicant rebuilt the vehicle or supervised its rebuilders. (2) Applicant personally inspected the completed vehicle and its

complies with all safety requirements set forth by the State of Alabama and any regulations promulgated thereunder. (3) The identification numbers of the restored vehicle

and its parts have not to the knowledge of the owner, been removed, falsified, altered or defaced. (4) The salvage certificate document or out of state certificate attached to the

application has not to the knowledge of the owner been forged, falsified, altered or counterfeited, and (5) All information contained on the application and its attachments is true and

correct to the knowledge of the owner.

I affirm, under penalties of perjury, that all information contained in this affirmation and its attachments is true and correct to the best of my knowledge.

___________________________

__________________________

_______________________________

TYPE OR PRINT NAME OF APPLICANT

SIGNATURE OF APPLICANT

DATE

APPLICATION FEE OF $75.00 AND TITLE FEE OF $15.00 (CERTIFIED FUNDS) MUST ACCOMPANY THIS APPLICATION. White AND YELLOW COPY TO BE FILED WITH

THE DEPARTMENT OF REVENUE- PINK COPY TO BE RETAINED BY THE APPLICANT DO NOT SUBMIT THIS APPLICATION UNTIL THE VEHICLE IS COMPLETELY

RESTORED AND READY FOR INSPECTION