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F~ M Towtng 8~ Auto Saiva~~, Inc. <br />30d 1 Main Street ~- 5 6 91 <br />- ' SFring€+eld, Oregon 97478 <br />Phone (541 ~ 746-5615 • Toll Free 1-800-386-5615 <br />24-HOUR TOWING <br />DATE_L~ / ~ ~ 20 0 ~ <br />MAKE ~~5~[ D/'/ l ~ ~ YEAR~~! _. LIC. NO. ~ ( " ' '`~ <br />? /Q / <br />wnnv rvvE '~ ~/.~ STATE <--' ! REG. NO. <br /> DESCRIPTION OF CHARGE 5 AMOUNT <br /> ~1" <br />TOWED / ~ <br />FROM ~ ~% ~ <br />TOWE~ / . <br />J <br />TO ~ ~P ~ <br />-!t /'1 <br /> <br />STORAGE <br />AT <br />RETOW <br />TO <br />FUSEES <br /> I~~ ~ F~r ~ ~~ <br /> J <br />DOLLIE (S ~ <br />.jl <br />AUTHORIZED TOW <br /> TOTAL ~ <br />.---r'J~ <br />Thc undtt+igncd agrcc. joi ntly and scvcrally, io pay F& M Towing & Au~o Sal- CHARGES ~ <br />~~ <br />~~~;~.~~~.. ..~~~~~~~~~„~~~~~..r,.o~..,..,..,....~.,..._...__....__...__...._~------- - <br />for ~hc .crviccx dc+cribcd abovc. Imcrest at thc ra~c of 10"/~ pcr annum (rom datc <br />ahall also bc paid. Thc undcrsigncd furthcr agrcc and undcrstand ~hat F& M Towing & Amo Saivagc, tnc. may foiward ibi, accoum w ~hc~r <br />attomcys or agcm for collection upon thc cxpiiation vf xaid 30 days and in that cvcn~ thc undcrsigncd. join~ly and .cvcrally, agrcc ~o pay a laic <br />-- oaymcnt .c~vicc chargc of SS 00, pluv a rca.onabic artomcy'z fcc to bc fixcd by ~hc cowi in casc suiic or ac~ion is institutcd ~o collcci thc wholc <br />~r pan of such amoum. plus auancy's kc. ncccc~+itatcd by appcls 6om ccixion of a lowcr coun <br />/"\ <br />NED - <br />~ X <br />ADDRESS <br />Tbc undcnigncd agrcc. tha~ F Sc M Towing & Aum Salvagc, Inc. ~NSURED'S NAME <br />shall not bc hcld liabic for damagc to thc abovc dc.cribed vchiclc <br />or cquipmcm, occurring dunng ~hc rcmoval or n~an.apai cauud by <br />ihcposition,tcea~iona~conditionofthcvch~clc. F&MTowing& $IGNATURE <br />Autu Sal~agc. Inc. will bc hcld harmicx, by thc andcrcigncd finm <br />all clann. oP any nature ariaing from ~hc rcmoval ot thc vchiclc INSURANCE CO. <br />fran any loca~ion, public or privatc <br />POLICY It <br />X AGENT7t <br />I have authorized F 8 M TOWING & AUTO SALVAGE INC. to bw my car and <br />oro <br />I hereby outhorized my Insurance Company to make payment to this tow+ng agency on <br />anoum <br />my behalf. <br />Signoture Dole <br />OW NER'S <br />NAME <br />ADDRESS <br />___..r <br />