OHIO BUREAU OF MOTOR VEHICLES POLICE REPORT TO LAW ENFORCMENT AGENCIES: 4501: 1-4-02 of the Ohio Administration code requires that this form be completed for each applicant for Salvage Dealer and related types of licenses issued by the State of Ohio. We respectfully request completion of this form with respect to any arrests or violations. (other than minor traffic violations) 1. PLEASE PRINT LEGIBLY OR TYPE THE FOLLOWING INFORMATION NAME OF PERSON APPLYING FOR LICENSE SOCIAL SECURITY NUMBER DATE OF BIRTH RESIDENCE ADDRESS CITY STATE ZIP CODE NAME OF COMPANY CITY STATE ZIP CODE COUNTY 2. USING A BLACK PEN, SHADE IN A BOX IN EACH COLUMN, UNDER DEALERSHIP COUNTY, TO INDICATE THE COUNTY NUMBER IN WHICH YOUR DEALERSHIP IS LOCATED. SEE CHART BELOW FOR THE APPROPRIATE COUNTY NUMBER. DEALERSHIP COUNTY 01 ADAMS 16 COSHOCTON 31 HAMILTON 46 LOGAN 61 NOBLE 76 STARK 02 ALLEN 17 CRAWFORD 32 HANCOCK 47 LORAIN 62 OTTAWA 77 SUMMIT 03 ASHLAND 18 CUYAHOGA 33 HARDIN 48 LUCAS 63 PAULDING 78 TRUMBULL 0 0 0 0 04 ASHTABULA 19 DARKE 34 HARRISON 49 MADISON 64 PERRY 79 TUSCARAWAS 1 1 1 1 05 ATHENS 20 DEFIANCE 35 HENRY 50 MAHOINING 65 PICKAWAY 80 UNION 2 2 2 2 06 AUGLAIZE 21 DELAWARE 36 HIGHLAND 51 MARION 66 PIKE 81 VAN WERT 3 3 3 3 07 BELMONT 22 ERIE 37 HOCKING 52 MEDINA 67 PORTAGE 82 VINTON 4 4 4 4 08 BROWN 23 FAIRFIELD 38 HOLMES 53 MEIGS 68 PREBLE 83 WARREN 5 5 5 5 09 BUTLER 24 FAYETTE 39 HURON 54 MERCER 69 PUTNAM 84 WASHINGTON 6 6 6 6 10 CARROLL 25 FRANKLIN 40 JACKSON 55 MIAMI 70 RICHLAND 85 WAYNE 7 7 7 7 11 CHAMPAIGN 26 FULTON 41 JEFFERSON 56 MONROE 71 ROSS 86 WILLIAMS 8 8 8 8 12 CLARK 27 GALLIA 42 KNOX 57 MONTGOMERY 72 SANDUSKY 87 WOOD 9 9 9 9 13 CLERMONT 28 GEAUGA 43 LAKE 58 MORGAN 73 SCIOTO 88 WYANDOT 14 CLINTON 29 GREENE 44 LAWRENCE 59 MORROW 74 SENECA 15 COLUMBIANA 30 GUERNSEY 45 LICKING 60 MUSKINGUM 75 SHELBY Butler Co. = 09 6 $ 0 3 / ( 3. LIST ARRESTS and/or VIOLATIONS BELOW: IF NONE, PLEASE INDICATE NONE Police Identification Seal or Stamp X SIGNATURE OF OFFICER/TITLE/DATE Return to: Ohio Bureau of Motor Vehicles, Attn: Dealer Licensing Section, P.O. Box 16521, Columbus, Ohio 43216-6521 www.OhioAutoDealers.com  %09  American LegalNet, Inc. www.FormsWorkflow.com