REPAIR AUTHORIZATION FORM


Preferred Location:
Drop Off Date:
Drop Off Time:
Rental Needed?YesNo
Customer Name:
Address*
Vehicle Year, Make and Model:
Insurance Company:
Your Email:
Phone:
Type:
Secondary Phone:
Type:
Preferred Method of Contact:

THIS FORM AUTHORIZES BRANDYWINE COACH WORKS,INC. TO PERFORM REPAIRS AND OR TEST DRIVE YOUR VEHICLE, ONCE WE HAVE REACHED AN AGREED PRICE. THE REPAIR PROCESS INCLUDES ACCESSING ALL RELEVANT VEHICLE INFORMATION AND PERFORMING DIAGNOSTIC SCANS. UPON COMPLETION OF THE REPAIRS WE MUST RECEIVE PAYMENT IN FULL EITHER BY CHECK, CASH, CREDIT CARD, MONEY ORDER OR INSURANCE COMPANY DRAFT.

POWER OF ATTORNEY


TO ENDORSE INSURANCE COMPANY CHECKS: KNOW ALL MEN BY THESE PRESENTS, THAT I HAVE CONSTITUTED, MADE AND APPOINTED DAVID M. SCHILTZ MY TRUE AND LAWFUL ATTORNEY TO SIGN AND ENDORSE CHECKS PAYABLE TO MY ORDER FROM THE INSURANCE COMPANY LISTED ABOVE FOR REPAIRS TO MY VEHICLE.


PAYMENT AUTHORIZATION


I AUTHORIZE THE INSURANCE COMPANY TO MAKE PAYMENT DIRECTLY TO BRANDYWINE COACH WORKS, INC. FOR THE REPAIR WORK BEING PERFORMED ON MY VEHICLE.

Customer Signature:
Date: