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City of Grand Forks, ND

Seamless@grandforksgov.com

255 N 4th Street, Grand Forks, ND, 58201, US

701-746-2682

City of Grand Forks

Request for Vehicle Information - Gas Drive-Off Program


* Required Field

Date / Time of Occurance

Date Picker

Amount / Dollar Value of Gasoline

I certify that I am submitting this request for vehicle information based upon United States Code, Title 18, Section 2721. I certify that the gasoline in question is legally owned by the business listed above, and the vehicle for which I am requesting information has obtained said amount of gasoline without proper payment. I understand that the information requested is to be used for the sole purpose of recovering a debt owed for gasoline, and for no other purpose.

In requesting and using this information, I acknowledge that this disclosure is subject to the Federal Driver's Privacy Protection Act (Public Law 103-322) and the North Dakota Law.

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorizing to represent.

Signature