HERITAGE COLLISION AND AUTO REPAIR

AUTHORIZATION FORM

5450 GULFTON ST. HOUSTON TEXAS, 77081 > BUS: 713-667-4888 FAX: 713-969-4838

*First Name and Last Name

Day Phone:

Cell:

*Email

Address:

Date

City:

State:

Zip

How did you hear about us?

Car or truck information:

Year

Make

Model

Color

Mileage

License Plate:

VIN #:

Insurance Company:

Insurance Phone

Claim #:

Deductible amount:

Notes:

*I hereby authorize the repair work to be done along with necessary materials and hereby grant you and for your employee’s permission to operate the vehicle herein described on streets, highways, or elsewhere for the sole purpose of testing and/or inspection. An express mechanic lien is hereby acknowledged on above vehicle to secure the amount of repairs there to. You are hereby notified in accordance to the Texas Motor Vehicle Laws Section 70.001-70.008 that your vehicle may be subject to repossession for return checks such as insufficient funds, account closed, stop payment, or stolen checks. You will also be obligated to pay the cost of the repossession and storage as a condition of reclaiming the vehicle

I agree

I Hereby authorize the teardown of my vehicle to assist in estimation and expedite repairs and understand that additional fees of the two hundred and fifty dollars ($250) in administration, five hundred dollars ($500) for teardown, a thirty five dollar ($35) plus tax charge for storage per day that the vehicle is on property and minimum transfer fee of one hundred dollars ($100) will be assessed if the vehicle is removed without repair

I agree

*Signature

heritagecollision@sbcglobal.net

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Authorization Form

HERITAGE COLLISION AND AUTO REPAIR

AUTHORIZATION FORM

5450 GULFTON ST. HOUSTON TEXAS, 77081 > BUS: 713-667-4888 FAX: 713-969-4838

Car or truck information:

*Please remove all personal items from vehicle; we cannot be held responsible!