NAME_____________________________________________________________________________________________

HOME PHONE_________________________________WORK PHONE________________________________________

CELLULAR____________________________________E-MAIL_______________________________________________

ADDRESS__________________________________________________________________________________________

CITY_____________________________________STATE______________________ZIP___________________________

MAKE/MODEL__________________________________________YEAR___________LICENSE____________________

REPAIRS NEEDED:__________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

PLEASE READ

A MINIMUM DIAGNOSTIC FEE  OF $60.55 PER ITEM + SHOP SUPPLIES MAY BE CHARGED.
DIAGNOSTIC FEE FOR ENGINE PERFORMANCE OR ELECTRICAL PROBLEMS IS $121.10 + SHOP SUPPLIES.
FULL PAYMENT FOR REPAIRS WILL BE DUE UPON DELIVERY OF THE VEHICLE. CHECKS ARE NOT ACCEPTED.
PERMISSION IS GIVEN FOR THE ABOVE VEHICLE TO BE OPERATED BY THE EMPLOYEES OF
BEN WHITE AUTOMOTIVE ON LOCAL STREETS FOR TEST DRIVING PURPOSES.
INSURANCE FOR THE ABOVE VEHICLE IS THE RESPONSIBILITY OF THE OWNER OF THE VEHICLE.
ALL PHONE CALLS TO AND FROM BEN WHITE AUTOMOTIVE ARE RECORDED.
VEHICLES NOT PICKED UP AND PAID FOR WITHIN 30 DAYS OF COMPLETION MAY BE CONSIDERED ABANDONED.
ABANDONED VEHICLES MAY BE REPORTED TO THE CITY OF AUSTIN FOR REMOVAL OR ABANDONED VEHICLES
MAY HAVE A MECHANICS LIEN FILED AGAINST THEM.
I AUTHORIZE THE REPAIRS. (THE PRECEDING STATEMENT IS REQUIRED BY TEXAS DPS AS OF 10/10/2013).


PLEASE SIGN_____________________________________________________DATE_____________________________
Phone 512-440-0409  Fax 512-440-0467