Express Autobody

CUSTOMER REPAIR AUTHORIZATION

Name___________________________________________________________________RO#_________________________

Vehicle_______________________________________________________________________________________________

(Color) (Year) (Make) (Model) (License Plate)

AUTHORIZATION TO REPAIR

I hereby authorize Express Autobody to complete the necessary repairs to my vehicle. Express Autobody will provide me with an oral/written evaluation. I understand that payment in full is due upon release of the vehicle, including any supplement charges. I hereby grant you and/or your employees permission to operate my vehicle on streets, highways, or elsewhere for the purposes of testing, inspection or sublet repairs, and delivery or pick up. AN EXPRESS MECHANIC’S LIEN is hereby acknowledged on above vehicle to secure the amount of repairs thereto. I WILL NOT HOLD YOU RESPONSIBLE FOR LOSS OR DAMAGE TO VEHICLE OR ARTICLES LEFT IN VEHICLE IN CASE of fire, theft, accident or any other cause beyond your control. I authorize any and all supplements to be paid directly to Express Autobody.

AUTHORIZED/ACCEPTED BY:___________________________________ DATE:________________________

POWER OF ATTORNEY: For consideration of repairs made to this vehicle, I hereby grant my POWER OF ATTORNEY to sign or endorse any checks and/or drafts made payable to me, and release thereto, as settlement for my claim or damage to my vehicle.

AUTHORIZED/ACCEPTED BY:___________________________________ DATE:________________________

*****I HAVE REMOVED ALL UNATTACHED PERSONAL AND VALUABLE ARTICLES FROM SAID VEHICLE *****

I UNDERSTAND Express Autobody WILL NOT BE RESPONSIBLE FOR ANY BELONGINGS LEFT IN THE VEHICLE.

NOTICE PURSUANT TO SECTION 70.001, TEXAS PROPERTY CODE

I am the person or agent acting on behalf of the person, who is obligated to pay for the repairs of the motor vehicle herein described. I understand that this vehicle is subject to repossession in accordance with Section 9.503, Texas Business & Commerce Code, if a written order of payment for repairs is stopped, dishonored because of insufficient funds, no funds, or because the drawer or maker of the order has no account or the account on which it is drawn has been closed.

INSURANCE COMPANY______________________________CUSTOMER’S DEDUCTIBLE AMOUNT $_________

(PAYING FOR REPAIRS)

AUTHORIZED/ACCEPTED BY:___________________________________ DATE:________________________

CUSTOMER REQUESTS _____________________________________________________________________

Please print out this form, fill it out as completely as you can, and fax it to 512-869-4534.