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Tow Company Submission Form
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
Type of Tow
(Required)
Police tow: Police requested the tow
Private Party Impound: Tow requested by landowner
Owner Request: Owner of the vehicle called for the tow(please give owners name and last known address.)
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
(Required)
Mailing Address
(Required)
Street Address
City
State
ZIP / Postal Code
County
(Required)
Your Email
(Required)
Phone
(Required)
FAX
(Required)
3: Vehicle Owner Information
(only required if vehicle owner requested tow)
Owner's First Name
Owner's Last Name
Owners Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please Attach a Copy Of The Tow Order
(Required)
Drop files here or
Select files
Max. file size: 20 MB.
4: Verification and Submission
Authorization
(Required)
AUTHORIZATION: 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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