G & C Automotive, LLC
717-733-0722
856 South State Street
Ephrata, PA 17522
Mon-Fri 8 am to 5 pm
To print this form: Copy and paste in Word, change font color to black, print.
To our early/late customers
1. Fill out the below form as completely as possible including your signature and date.
2. Park your car and secure it.
3. Place your key in this envelope.
4. Place your registration and insurance cards in this envelope.
5. Place the envelope through the slot in the back of the key drop.
Name: ______________________________ License Plate #______________________
Address: _____________________________ Mileage: _________________________
City: _________________________________ State: ___________________________
Contact phone number: ___________________ Alt number: _______________________
Year: __________________ Make: ______________ Model: ____________________
____ Change oil and filter
____ Cooling System Flush
____ Emissions Inspection
____ State Inspection
____ Brake Inspection
____ Tire rotation
____ Check Engine Light
____ Factory Recommended Service
____ Other service
Description of problem:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Terms Cash:
I hereby authorize the repair work hereinafter set forth to be done along with the necessary material and agree that you are not responsible for loss or damage to vehicle or articles left in the vehicle in case of fire, theft or any other cause beyond your control or for any delays caused by unavailability of parts or delays in parts shipments by the supplier or transporter. I hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways or elsewhere for the purpose of testing and/or inspection. An express mechanic's Lien is hereby acknowledged on above vehicle to secure the amount of repairs thereto.
Customer Signature: _______________________________________ Date: ________________
