Work Authorization

1

Customer & Company Information

Company/Fleet Name (if applicable)

Driver / Contact Name *

Please enter the driver or contact name

Phone Number *

Please enter a valid phone number (10 digits)

Billing Email Address *

Please enter a valid email address

2

Equipment / Vehicle Identification

Year / Make / Model *

Please enter the year, make and model

VIN / Serial Number *

Please enter the VIN or serial number

License Plate & State

Unit / Fleet Number

USDOT Number (For Commercial/Heavy-Duty Trucks)

Current Odometer / Hour Meter

Current Physical Location / Breakdown Landmarks *

Please enter the current physical location

3

Service Call & Dispatch Authorization

Non-Refundable Dispatch Fee: I acknowledge and agree to a non-refundable service call/dispatch fee of the amount shown below for the technician to travel to my roadside location. This fee is due regardless of whether the vehicle can be successfully repaired on the side of the road.

Dispatch Fee: $125

Initial Roadside Labor & Diagnostic Limit: I authorize initial roadside diagnostics and minor repairs. For extensive repairs exceeding the initial scope, the technician or shop dispatcher must secure my explicit verbal or written authorization.

Hourly Rate May Vary

4

Maryland Roadside Disclosures & Customer Rights

NOTICE (Maryland Commercial Law § 14-1002): For any repairs where the customer will be charged more than $50, you are entitled to a written estimate of the price and an estimated completion time before work begins. No additional or supplemental work outside the agreed-upon estimate will be performed without your verbal or written consent.

Roadside Liability & Hazard Disclosure: Mobile repair work is inherently hazardous. While our technicians take every safety precaution, the vehicle owner/driver acknowledges that roadside conditions (such as passing traffic, uneven ground, and weather) may restrict the scope of work that can safely be performed. If a vehicle cannot be safely repaired on-scene, the customer remains responsible for the dispatch and diagnostic fees incurred up to that point.

5

Mobile Terms and Conditions

Permission to Operate & Move

I grant permission to the technician to operate, test-drive, or move the vehicle/equipment at the roadside scene or on public highways for diagnostic and testing purposes.

Safe Work Environment

The driver agrees to follow all safety instructions provided by the technician while work is being performed, including remaining in a safe zone away from the active repair area.

Mechanic's Lien

An express mechanic's lien is acknowledged on the vehicle/equipment to secure payment for all authorized roadside labor, parts, and dispatch fees.

Parts & Breakdown Delays

The repair service is not liable for subsequent delays, towing needs, or secondary damages resulting from roadside parts availability or severe component failure.

6

Digital Authorization Signature

By checking the box and typing your name below, you certify that you are the vehicle owner, fleet manager, or authorized driver with the authority to bind payment for this vehicle.

I agree to the roadside service terms and authorize work to begin.

Please check the agreement box to continue

Authorized Signature *

Please type your full name as your signature

Date & Time Will be recorded on submission