Free Form 10.010.b - Oregon

CERTIFICATE OF SERVICE

I hereby certify that I served the foregoing Petition for Judicial Review on: Manager DMV Hearings Driver and Motor Vehicle Services Branch of the Oregon Department of Transportation 1905 Lana Avenue NE Salem, Oregon 97314 and, Attorney General or Designee General Counsel Division Transportation - Implied Consent Unit 100 Justice Building Salem, Oregon 97310 by mailing by registered or certified mail to those persons a true and correct copy thereof, certified by me as such, placed in a sealed envelope addressed to them at the addresses set forth, and deposited in the United States Post Office at , Oregon, on (date) with the postage prepaid.

G Petitioner G Attorney for Petitioner (Please check one of the above)

Form 10.010.b ­ CERTIFICATE OF SERVICE FOR PETITION OF JUDICIAL REVIEW OF ORDER OF DMV ­ UTCR 10.010 (Rev. 8-1-02) TCG-5-F2 UTCR App. Page 41