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F & M Towing & Auto Salvage, Ine. <br /> 3001 Main Street W ~ ~ 2 <br /> Springfield, Oregon 97478 <br /> Phone (541 ~ 746-5615 • To{I Free 1-800-386-Sb 15 <br /> 24-HOUR TOWING <br /> - DATE ~ / ~ ~ 20L~~ <br /> " <br /> r" <br /> MAKE ~ ~'g'~"` ~ ~ ~ YEAR LIC. NO.~~~~t ~ <br /> BODY TYPE ~ ' • Q " ' ' '~'j Y' "`'STATE L/ L REG. NO. <br /> ~/J DESCRIPTION OF CHARGE `~S AMOUNT <br /> FROMD ~ fit f•! ~ ~/`V L- ~i c.~(~.-^~l <br /> TOWED p <br /> STORAGE <br /> AT <br /> RETOW <br /> TO <br /> FUSEES <br /> OUTSIDE LABOR <br /> 8 RECOYERY <br /> DOLLIE <br /> AUTHORIZED TOW <br /> TOTAL ) ~ ,r <br /> The undersigned agrcc. jonntly and severally, to pay F & M Towing & Auto Sal- CHARGES / ~ <br /> vage, Lte. within shiny UD) days fi~om date of service, the amount set (ash above <br /> for the services described above. Interest at the rate of 10' ~ per annum from date <br /> shall also be paid The undcrsigncd further agrcc and understand that F & M Towing & Aulo Salvage, Inc. may forward thin accoum io their <br /> anomcyx or agem For collection upon the czpiration of said i0 days and in that evcm the undcrsigncd, jointly and severally. agrcc to pay a late <br /> payment service charge or 55.00. plus a reasonable attomcyk (ec to be fined by the coon incase suite or action is instituted to collect the whole <br /> ~r pan of such amount, plus mt cy'.a kes neccessitated by appeals from a decision of a lower coup <br /> <br /> ~ NED <br /> BY X <br /> ADDRESS <br /> The undcrsigncd agrcc, that F & M Towing & Auto Salvage. Inc. <br /> dtall not be field liable for damage to the above described vchiclc INSURED'S NAME <br /> or equipment, occurring during the removal or transport caused by <br /> the position, location or condition of the vchiclc F & MTowing& SIGNATURE <br /> Auto Salvage. Inc will be held harmless by the undcrsigncd from <br /> all claims of any nature arising from the removal of the vchiclc INSURANCE CO. <br /> from tiny location, public or private. <br /> POLICY !t <br /> X AGENT~t <br /> Y have authorized F 8 M TOWING & AUTO SALVAGE INC. to tow my car and <br /> oro <br /> I hereby outhorized my Insuronce Company to make payment to this towing agency on <br /> Amount <br /> my behalf. <br /> Signature Date <br /> OWNER'S `,J ~ 4,+~ % J'" //r~- <br /> NAME t.- i " c'~ . CJ~,.~~' <br /> ADDRESS <br /> <br />