EagleValley

Phone: 780 542 4444

Email: admin@evrr.ca

Fax: 780 542 7986

mandatory Fields *

Last Name *

First Name *

Midle Name *

Address 1 *

Address 2

City *

Provice *

Postal Code *

Home Telephone

Work Telephone

Cellular Phone *

Fax No

Email *

Drivers License Number *

Do you own the vehicle/ RV being deposited?

Yes

If No, Please complete ownership Information below.

Owner's Name

Address 1

Address 2

City

Provice

Postal Code

Telephone

If you are not the owner of the vehicle deposited, Are you authorized by the owner to possess the vehicle?

Yes

Relationship to the owner of the vehicle

Employee

Contractor

Agent

Friend

Family Member

Other

Does any other person or party have a lien on or security interest in the vehicle being deposited?

Yes

If yes, Name/ Adress/ Phone No. of person/ party