Name_____________________________________ Date__________________

Address_________________________________________________________

Home Phone__________ Work Phone ____________ Email ________________

Year_________ Make_________________ Model____________ Color _______

I hereby authorize repair of the above vehicle. I agree that CSNT Paint & Body is not responsible for loss or damage to this vehicle and or loss of articles left in the vehicle caused by fire, theft, or any other cause beyond our control, or for delays caused by the unavailability of parts or shipping delays. I also grant permission to CSNT Paint & Body employees to operate the above stated vehicle for the purpose of testing or inspection. I understand and agree that to secure payment for the repairs thereto, an expressed mechanic's lien on the above vehicle is acknowledged and I further agree to pay reasonable attorney's fees and court costs in the event that legal action is required. I understand that whenever a front, back or side glass is removed there is a chance of breakage. I understand that CSNT Paint & Body is not responsible for the cost of replacement and that I must submit a glass claim to my insurance company for payment of replacement glass. If supplemental damages, related to this claim are found after commencement of repairs, I authorize CSNT Paint & Body to perform those repairs with the understanding that the responsible insurance company will bear the cost. I understand storage charges in the amount of $17.00 per day will commence on the eighth day after completion of repairs.

TERMS: The total amount of the repair charges must be paid before release
of the above vehicle.

VEHICLE OWNER'S SIGNATURE:

___________________________________ DATE: _______________

DIRECT PAY AUTHORIZATION
I hereby authorize payment to be made directly to CSNT Paint & Body Shop for repairs made to my vehicle.

VEHICLE OWNERS SIGNATURE