DMV
DEPARTMENT OF TRANSPORTATION
DRIVER AND MOTOR VEHICLE SERVICES
1905 LANA AVE NE, SALEM OREGON 97314
YES
&/2--534"%&5,,9#/-0,%4%$!.$3)'.%$n).3425#4)/.3/."!#+
.!-%02).4,!34&)234-)$$,%
CUSTOMER INFORMATION
/$,)$#534/-%2 34!4%/&)335% -%33!'%0(/.%
NO
!$$2%33342%%4#)4934!4%!.$:)0#/$%
0,!4%.5-"%2 34!4%02/6).#%/&2%')342!4)/.
VEHICLE INFORMATION
9%!2
!
+ % " / $ 9 3 4 9 , %
)FTHISISAMOTORIZEDVEHICLEISTHEGROSSVEHICLEWEIGHTRATING'672 OVERPOUNDS
)FTHISISANONMOTORIZEDVEHICLEISTHELOADEDWEIGHTOVERPOUNDS
VIN INSPECTION
YES
YES
/ $ % ,
NO
NO
VIN LOCATION
6)3)",%4(2/5'(
7).$3()%,$
"/$9,%&4 (DRIVER SIDE)
"/$92)'(4
%.').%#/-0!24-%.4
425.+
&2!-%
/.%.').%
/4(%2???????????????
Check ALL boxes that apply – At least one box MUST be checked in each column
VIN TYPE VIN ATTACHED BY CONDITION OF VIN FED STANDARDS STICKER
-%4!,0,!4%
34!-0%$/."/$9
34!-0%$/.&2!-%
,!"%,
/4(%2???????????????
??????????????????????
./46)3)",%
2/3%44%2)6%43
2/5.$2)6%43
3#2%73
!$(%3)6%
34!-0%$
/4(%2???????????????
??????????????????????
!00%!23/+!9
!,4%2%$4!-0%2%$
),,%')",%$!-!'%$
-)33).'
#!../4,/#!4%
./.%.%7,9"5),4
!33)'.%$"9$-6
/&&)#%3%%"%,/7
/4(%2???????????????
!'2%%37)4(6).
$)3!'2%%37)4(6).
),,%')",%$!-!'%$
-)33).'
.!&/26%()#,%
/4(%2???????????????
??????????????????????
I certify that I have physically inspected the vehicle described above to verify the VIN and found the VIN in the condition indicated.
– And / Or –
I certify by checking one of the LEV boxes above that I am an Oregon licensed dealer with this vehicle in my stock and have checked its under hood emission label to verify compliance with LEV standards.
.!-%/&).30%#4/202).4%$ !'%.#9OR$%!,%23()0
!$$2%33 4%,%0(/.%
$!4%/&).30%#4)/.
3)'.!452%/&).30%#4/2
X
/2%'/.$%!,%2.5-"%2 2%#%)04.5-"%2
LAW ENFORCEMENT REFERRAL
2%!3/.&/22%&%22!, $!4%/&2%&%22!,
SHADED AREA FOR DMV USE ONLY
I have assigned the following number to the vehicle described above:
CONTROL NUMBER ASSIGNED VIN
OR
VIN PLACEMENT: (TO WHAT PART OF THE VEHICLE WAS THE VIN DECAL ATTACHED?)
V
COUNTER NUMBER AND DATE SIGNATURE OF OREGON DMV REPRESENTATIVE
X
735-11 ( -1 ) STK # 300006

INSTRUCTIONS
/23REQUIRESA6).INSPECTIONWHEN
s !FOREIGNOUTOFSTATEOROUTOFCOUNTRY VEHICLEISBEINGTITLEDIN/REGON s s
4HEVEHICLEWILLBETITLEDASATOTALEDANDORANASSEMBLEDRECONSTRUCTEDORREPLICAVEHICLE3URRENDER OF THETITLE
TO $-6 HAS BEEN OR IS REQUIRED BECAUSE THE VEHICLE HAS BEEN WRECKED DISASSEMBLEDSUBSTANTIALLYALTERED
ORTOTALEDORWHEN$-6HASRECEIVEDNOTICEOFTHISWHETHERORNOTTHEVEHICLEISBEINGRETITLEDASASSEMBLEDOR
RECONSTRUCTED s $-6HASREASONTOBELIEVETHEVEHICLEWASNOTCERTIFIEDBYTHEORIGINALMANUFACTURERASCONFORMINGTOFEDERALSTANDARDS
6EHICLES LOCATED IN /REGON MAY BE INSPECTED BY /REGON $-6 AN /REGON LAW ENFORCEMENT AGENCY UNDER AGREEMENT
WITH$-6AN/REGON0OLICEAGENCYWITHCUSTODYOFTHEVEHICLEORAN/REGONVEHICLEDEALER *
* $EALERSMAY only INSPECTAVEHICLE in their stock BEINGTITLEDIN/REGONFORTHEFIRSTTIME!DEALERMAY
not
INSPECTAVEHICLEBEINGTITLEDASTOTALEDANDORASSEMBLEDRECONSTRUCTEDORAREPLICAVEHICLEAVEHICLETHAT
APPEARSTOHAVEBEENWRECKEDORDESTROYEDORAVEHICLEIMPORTEDFROMANOTHERCOUNTRYTHATHASNOTBEEN
CERTIFIEDBYTHEORIGINALMANUFACTURERASCONFORMINGTO53FEDERALVEHICLESTANDARDS
6EHICLESLOCATEDOUTOFSTATEMAYBEINSPECTEDBYTHE$-6ORANYLAWENFORCEMENTAGENCYINTHATSTATE
LEV Boxes: $-6WILLNOTISSUEREGISTRATIONFORMODELYEARORNEWERMOTORVEHICLESWITHMILESORLESSONTHE
ODOMETERATTHEINITIAL/REGONREGISTRATIONUNLESSTHEVEHICLEMEETSTHE,OW%MISSION6EHICLE,%6 REQUIREMENTORIS
OTHERWISEEXEMPT4HE,%6CHECKBOXESONTHEFRONTOFTHISFORMAREFORUSEONLYBY/REGONLICENSEDVEHICLEDEALERS
WITHTHEVEHICLEINTHEIRSTOCKTOCERTIFYTHATTHEYVIEWEDTHEUNDERHOODEMISSIONLABELOFTHATVEHICLEANDAREVERIFYING
THATTHELABELINDICATESCOMPLIANCEWITHTHE,%6REQUIREMENTORDOESNOTCOMPLY!h9ESvINDICATORONTHEFRONTOFTHIS
FORMWILLNOTBEVALIDUNLESSTHELABELWASCHECKEDBYTHEDEALERTHEFORMCONTAINSCOMPLETEVEHICLEINFORMATIONAND
THEFORMISSIGNEDANDDATEDBYSUCHDEALERORANAUTHORIZEDEMPLOYEEOFTHEDEALERSHIP$EALERSMAYNOTCHARGEAFEE
TOCHECKCOMPLIANCEWITHTHE,%6REQUIREMENT
4HEINSPECTORMUSTPHYSICALLYINSPECTTHEVEHICLE
4HE 6). MUST BE LOCATED IN AN AREA PRESCRIBED BY THE VEHICLE MANUFACTURER 4HIS INFORMATION IS AVAILABLE TO LAW
ENFORCEMENTTHROUGHTHE.ATIONAL)NSURANCE#RIME"UREAU.)#"
4HISFORMMUSTBECOMPLETEDINFULL)NCOMPLETEFORMSMAYRESULTINTHEREQUESTFORANEWINSPECTION4HEFORMMUSTBE
SIGNEDDATEDANDINCLUDETHEINSPECTORgSNAMEAGENCYORDEALERNAMEANDADDRESS
REFERRAL VIN
4OBECOMPLETEDBYLAWENFORCEMENTAGENCYUNDERAGREEMENTWITH$-62EIMBURSEMENTONLYMADEIFSUBJECTVEHICLEIS
REFERREDBY$-6ANDFORMISCOMPLETEDINFULL
YES NO
VINS IDENTIFIED
&2!-%
CHECKED NCIC AND LEDS: YES NO
"/$9
CHECKED NCIC AND LEDS: YES NO
%.').%
CHECKED NCIC AND LEDS: YES NO
CHECKED FOR HIDDEN VINS:
3)'.!452%/&).30%#4).'/&&)#%2
X
02).4%$.!-%/&).30%#4).'/&&)#%2
YES NO – WHY NOT?: ____________________________________________
$0334.5-"%2 $!4%/&).30%#4)/.
!'%.#9.!-%
!'%.#9!$$2%33#)4934!4%!.$:)0#/$%
!SSIGNPRENUMBERED6).TAG.ONUMBERCANBEFOUNDORUNABLETODETERMINE6).FROMFRAMENUMBER
!SSIGNUNNUMBERED6).TAG6).CANBEDETERMINEDBUTPUBLIC6).ISDAMAGEDILLEGIBLEORMISSING.OTEIN
h2EMARKSvTHENUMBERRECOMMENDEDFORUSE
.ONEEDTOASSIGN6).-ANUFACTURER6).ISREADABLEANDPLACEDCORRECTLYPER.)#"