The vehicle

Registration number (A)

Date of first registration (DD/MM/YYYY) (B)

Vehicle identification number (E)

Vehicle mileage

Brand (D.1)

Type variant version (D.2)

Commercial name (D.3)

National genre (J.1)

Presence of the registration certificate

Yes, the certificate is present

No, the certificate is absent

Former owner

Type of person

Physical

Moral

Gender

Male

Female

First name

Last name

Street number

Extension (bis, ter...)

Type and Name of the road

Postal code

Town

I certify:

Transfer

Transfer for destruction

Sale date (DD/MM/YYYY)

Sale time (HH:MM)

Having given the new owner a certificate issued less than fifteen days ago by the Minister of the Interior, attesting on its date of issue to the administrative situation of the vehicle

That this vehicle has not undergone any significant transformation likely to modify the indications of the certificate of conformity or the current registration certificate

That this vehicle is transferred for destruction to a professional in the destruction of end-of-life vehicles (ELV) approved

New owner