Vehicle Drop Off

Please complete the information below. You have the option to submit your information or print the form and bring it with you when leaving your vehicle for repairs.

Name: Name: First Last
Are you a First Time Customer?
New Customer Address: New Customer Address:
Street Address City State / Province / Region Postal / Zip Code Country
Which Rowleys Tires & Automotive Services
location will you be leaving your vehicle?
Referred by:
What is the best way for us to contact you?

What is the best way for us to contact you? Home Phone Mobile Phone Work Phone Email
Home Phone: Home Phone: - ### - ### ####
Mobile Phone: Mobile Phone: - ### - ### ####
Work Phone: Work Phone: - ### - ### ####
Email:
CALL ME FIRST IF REPAIR COST WILL EXCEED:
(Please enter dollar amount)
Vehicle Information
Vehicle Make & Model:
Vehicle Yeaar:
Vehicle Color:
Date you need your vehicle back: Date you need your vehicle back: / MM / DD YYYY
Time you need your vehicle back: Time you need your vehicle back: : HH MM AM/PM
Vehicle Problems

Please answer he questions below regarding the repairs of your vehicle:
Please describe the symptoms of concern:
When did the problem first happen?
How often does the problem happen?
Does the problem occur in the following situations?
(Please check all that apply)

Does the problem occur in the following situations?
(Please check all that apply) Accelerating Slowing Idle Steady Speed When Vehicle is Cold When Vehicle is Warm Other Other
Are your warning lights on?
Is your vehicle effected by damp weather?
Have you had this problem serviced before?
Are there any other ways this vehicle does not function correctly?
Do you need any additional repairs while your vehicle is in for service?
I hereby aurthorize the servicing/testing of my vehicle and grant you and your employees permisstion to operate my vehicle on streets, highways, or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is here by acknowledged on above vehicle to secure the amount of repairs thereto. I also acknowledge that you are not responsible for loss, damage, or articles left in autos in case of fire, theft or other cause beyond your control.
I authorize a minimum $69.95 Testing Fee (Multiple Electrical/Diagnostic problems may require more time)
OR
I authorize the above repair(s) to be performed as previously agreed.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
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Vehicle Drop Off

Vehicle Drop Off

Vehicle Information

Vehicle Problems

I authorize a minimum $69.95 Testing Fee (Multiple Electrical/Diagnostic problems may require more time) OR I authorize the above repair(s) to be performed as previously agreed.

I authorize a minimum $69.95 Testing Fee (Multiple Electrical/Diagnostic problems may require more time)
OR
I authorize the above repair(s) to be performed as previously agreed.