AUTHORIZATION FOR AUTOMOTIVE ACCESS
I hereby certify that I have the authority to gain access for the vehicle indicated below. I agree that the information I am providing is true and correct. Further, to the maximum extent permitted by applicable law, I agree to indemnify and hold harmless Locksmith Eugene Oregon and related parties providing security information from any and all liability or claims that may arise from the performance of this service.
Vehicle Owner/Customer Name: *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Driver’s License Number *
Your answer
State Of Issued License *
Your answer
Vehicle Year *
Your answer
Make *
Your answer
Model *
Your answer
Color
Your answer
License Plate
Your answer
Vehicle ID Number (VIN) (17 characters) *
Your answer
ID & Vehicle Documents File Upload (Follow Link, then come back to submit)
Your answer
Authorized Individual - First and Last Name
(if not the owner, who is allowed the keys or access)
Your answer
First Name, Last Name *
(Participant) Electronic Signature Verification
Your answer
I, the undersigned, verify that the above informed consent procedure has been followed *
Required
Date *
MM
/
DD
/
YYYY
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