Submission Form – Oregon Lien Service

1: Vehicle Information

Year(Required)

Make(Required)

Model(Required)

Plate(Required)

State(Required)

VIN(Required)

Service Date(Required)

Service amount (not inlcuding storage)(Required)

Daily Storage Rate(Required)

Appraised Value(Required)

Under $1000

Over $1000

Over $2500

Appraised Value (Verified)(Required)

Under $1000

Over $1000

Over $2500

Additional information about the vehicle

2: Business Information

Company Name(Required)

First Name(Required)

Last Name(Required)

Physical Address(Required)

Street Address City State ZIP / Postal Code

County

Mailing Address(Required)

Street Address City State ZIP / Postal Code

County

Phone(Required)

Email(Required)

Owner Request(Required)

Owner of the vehicle requested repairs

3: Vehicle Owner Information

Owner's First Name

Owner's Last Name

Mailing Address

Street Address City State ZIP Code

4: File Upload

Please Attach a Copy Of The Repair Order For Your Lien(Required)

Drop files here or

Max. file size: 20 MB.

5: Surety Bond Requirements

Surety Bond Authorization(Required)

By checking this box I confirm that our company is in compliance with the surety bond requirements of the State of Oregon. This check box constitutes a digital signature and must be checked to compete this lien. (If you have any questions about obtaining a bond or submitting the bond please give us a call.)

I agree to these terms.

6: Terms and Submission

Authorization(Required)

I authorize Oregon Lien Source to Act on my behalf to obtain information and to give notice concerning a vehicle(s). - 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 checkbox constitutes a digital signature, and must be checked to process this Lien Service Order.

I agree to these terms.

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Saturday & Sunday	Closed