1. Complete the following information then print and sign this form.
2. Leave your LOCKED car on our lot.
3. Place your keys and this form in the provided envelope.
4. Drop the envelope in the mail slot at the side of our building.

Contact Information:	Vehicle Information:
Name:	Year:
Address:	Make/Model:
City: Zip:	Color:
State:	License Number:
Home Phone:	Mileage:
Business Phone:	Pickup Day/Time: AM PM
Check the service(s) you want performed:
Mile Inspection	Mile Diagnosis
State Inspection	Emissions Inspection
Chassis Lubrication	Change Engine Oil
Change Oil Filter	Change Transmission Fluid
Repack Front Wheel Bearings	Tune Engine
Replace Brakes	Replace Muffler
Adjust Brakes	Replace Belts
Replace Hose	New Battery
Inspect/Repair Air Conditioning	Inspect/Repair Heating System
Replace Shocks	Check Transmission
Replace Radiator	Repair Lights
Oil Leaks – Front	Oil Leaks – Rear
Replace Clutch	Body Damage
Undercoat	Replace Tires: All Four Front Rear Other:
Other Work or Additional Information:

I hereby authorize the above repair work to be done along with the necessary materials, and hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic’s lien is hereby acknowledged on the above vehicle to secure the amount of repairs and/or service thereto. Our facility is not responsible for unavailability of parts or delays in parts shipments neither beyond our control nor for loss or damage to vehicle or articles left in vehicle in case of fire, theft, or any other cause beyond our control.

Please Sign Here______________________________     Date:___________________________