Transcription of ST/PROV - oregon.gov
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Example: tourism industry
ST/PROV - oregon.gov
DO NOT WRITE IN SPACE ABOVEOREGON WEIGHT RECEIPT AND TAX IDENTIFIER APPLICATION(SEE INSTRUCTIONS ON REVERSE)DO NOT WRITE IN SPACE BELOWEFFECTIVE DATEPROOFED DATEPROOFED BYDATE KEYEDKEYED BYFEESRECEIPTREINSTATEMENTSUSPENSION459 TOTAL PAIDMLGFM12 FORM 735-9076 (1-18)CERTIFICATION: I HEREBY CERTIFY THAT THE STATEMENTS CONTAINED IN THIS APPLICATION ARE TRUE AND CORRECT; NO MATERIAL FACT HAS BEEN OMITTED; THERE IS NOT A PERSON HAVING ANY INTEREST, DIRECTLY OR INDIRECTLY, IN THE OWNERSHIP OF THIS OPERATION EXCEPT AS SPECIFIED ABOVE; AND THAT THE OWNERSHIP AS DESIGNATED WILL AT ALL TIMES HAVE FULL POSSESSION AND CONTROL OF ALL MOTOR VEHICLES OPERATED OR REGISTERED UNDER THIS NAMEDATETITLEOWNEDLEASEDSOLOAXLCOMB #4 AXLCOMB #3 AXLCOMB #2 AXLCOMB #1 AXLHUBKMREASON FOR APPLICATIONADD VEHICLERENEW VEHICLEAMEND VEHICLE (LIST VARIABLE BEING AMENDED) oregon DEPARTMENT OF TRANSPORTATIONMOTOR CARRIER TRANSPORTATION DIVISION 3930 FAIRVIEW INDUSTRIAL DRIVE SE SALEM OR 97302-1166 PH (503) 378-6699 FAX (503) 37
do not write in space above. oregon weight receipt and tax identifier application (see instructions on reverse) do not write in space below. effective date
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