Washington Revised Code Title 46. Motor Vehicles § 46.75.030. Self-certification form

(1) The name and address of the eligible entity and its registered agent within Washington, including the registered agent's name, address, and driver's license number, and any other information the department may require;

(2) The name of the jurisdiction in which the personal delivery device will be operated;

(3) An acknowledgment by the eligible entity that:  (a) Each personal delivery device will display a unique identification number and other information specified in RCW 46.75.020(8);  and (b) the registered agent is responsible for any infraction committed by its personal delivery device;

(4) An affirmation by the eligible entity that it possesses insurance as required in RCW 46.75.020;

(5) A list of any incidents, as described in RCW 46.75.020(5), and any traffic infractions, as described in RCW 46.75.050, involving any personal delivery device operated by the eligible entity in Washington state in the previous year;  and

(6) A list of each device identified by a unique identification number that the eligible entity intends to operate in the state during the year and payment of a fee of fifty dollars per personal delivery device listed.  The fee must be deposited into the motor vehicle fund.  The list must be updated and the fee paid prior to the eligible entity operating a device not listed in the annual self-certification.