"Record of Transaction | |
Dealer certificate # _________________ | # _________________________ |
(Printed on the form) | (Transaction number printed on the form) |
(1) Description of Property - ____________________________________ | |
__________________________________________________________________ | |
__________________________________________________________________ | |
__________________________________________________________________ | |
__________________________________________________________________ | |
(2) __________________, 19__ | (3) __________________________ |
(Date) | (Name of Dealer/Employee) |
(4) _______________________, | ________________________, 19__ |
(Name of Customer) | (Date of Birth) |
___________________________, | ______________________________ |
(Driver's license No./Mich. Personal ID Number) | (Street Address) |
__________________ ___________ | |
(City & State) (Zip) | |
(5) _______________________ | ______________________________ |
(Price Paid) | (County of Residence) |
(6) _______________________ | |
(Check no., bank draft no., money order no., or cash) | |
__________________________________________________________________ | |
(Name of police agency of city, village, or township in which customer resides) | |
Thumbprint | ______________________________" |
(Signature of Customer) |
MCL 445.484