Cyclop Collision Center Repair Authorization

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Customer Name Customer Name * First Last
Phone Phone - ### - ### ####
Address Address *
Street Address
Address Line 2 City State / Province / Region Postal / Zip Code Country
Vehicle Year
Vehicle Make *
Vehicle Model *
Email Address
Take a Picture of My Drivers License or ID *

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Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
***PART PRICE SUBJECT TO INVOICE*** AUTHORIZED AND ACCEPTED: You are hereby authorized to make the above specified repair. I understand that payment in full will be due upon release of vehicle, including additional supplemental damage charges, and hereby grant you and - or your employees, permission to operate the vehicle here in described on streets, highways or elsewhere for the purpose of testing and/ or inspection.
In express mechanic's lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto. I accept responsibility for any attorney or collection fees related to the collection of unpaid balances. You will not be held responsible for loss or damage to vehicle or articles left in vehicle in case of fire, theft, accident or any other cause beyond your control. Old parts removed from vehicle will be junked unless otherwise instructed!
I authorize any and all supplements payable direct to you. I authorize you to act as power of attorney to sign insurance checks to pay for damages to above vehicle.
**FINAL REPAIR BILL**