Full Name *

Home Address *

Cell Phone *

Vehicle Make, Model & Year *

Desired Pickup Date (Monday-Friday) *

Desired Pickup Time *

Services Requested (Please Provide As Much Detail As Possible) *

Method Of Payment *

I Request Delivery Service Upon Completion To The Above Noted Address.

Invoice Authorization: I hereby authorize the repair work herein set forth to be done along with the necessary material and agree that to the extent permitted by law, you are not responsible for loss or damage to vehicle or articles left in vehicle in case of fire, theft or any other cause beyond your control or for any delays caused by unavailability of parts or delays in parts shipments by the supplier or transporter.I 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. Until payment in full of the within account, I hereby acknowledge the existence of a mecanic's lien in favor of the within dealer on the vehicle described herein in respect of the material supplied and services rendered under this work order for the full amount charged therefore. I further acknowledge that the said lien shall continue in force at all times, whether the vehicle is in my possession or possession of the dealer, until the within account is paid in full.Transportation Authorization: I hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways or elsewhere for the purposes of providing complimentary pickup and drop off service as noted above. I hereby acknowledge I am responsible to ensure valid insurance and registration is located in the vehicle being transported prior to pickup. I hereby release Heartland Ford Sales Inc. from any claims of damage or loss to vehicle or articles left in the vehicle in case of theft, accident, or acts of God.