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r y <br /> F & M Towing & Auto Salvage, Ine. <br /> 3001 Main Street W ~ ~ ~ ~1 <br /> Springfield, Oregon 97478 .J <br /> Phone (541 ~ 746-5615 • Toll Free 1-800-386-Sb 1 S <br /> 24-HOUR TOWING <br /> / DATE ~ 20 C;' <br /> / ~ r <br /> MAKE fl lY 9! YEAR /r LIC. NO. <br /> BODY TYPE ~p ~a gTATE ~~5~ f ~ <br /> J~ REG. NO. <br /> DESCRIPTION OF CHARGE S AMOUNT <br /> TOWED ,d.~ <br /> FROM _ _i ! ~ ./~Y-+-.• ~.,jl ~i~~-J <br /> TOWED ~ / ~ ~ j G`, <br /> STORAGE <br /> AT <br /> RETOW <br /> TO <br /> FUSEES <br /> OUTSIDE LABOR _ - - <br /> 8t RECOVERY <br /> AUTHO IZED TOW ~~f? ~ ~ V <br /> ` - - _ TOTAL ~ ~ ,r' C~~ <br /> The undersigned agree. jointly and severally, m pay F & M Towing & Auto Sal- CHARGES 5 <br /> vage. Inc. within thnty (301 days from date of service. the amount set lath above <br /> for the services described above Interest at the rate of 10' <br /> ~ per annum trait date <br /> shall also be paid. The undersigned wwthn agrcc and understand that F & M Towing & Auto Salvage, Inc. may (oiward this account to their <br /> anomcys or agent for collection upon the expiration o(said 30 days and in that even the undcrstgned, jointly and severally, agrcc to pay a latt <br /> "ayment service charge of SS 00, plus a reasonable attorney's fee to be fixed by the covet incase suite or action ix instituted to collect the whole <br /> pan of such amount, plus auomcy's fees neccessitated by appeals from a decision of a lower cowl. <br /> ~ED <br /> BY X ~ <br /> ADDRESS <br /> The undersigned agrcc, that F & M Towing & Auto Salvage, Inc <br /> shall not be held liable fur damage to the above described vehicle INSURED'S NAME <br /> or equipment, a:curnng dunng the removal or nanspon cauzed by <br /> the position, location or condition ofthc vchrclc. F&MTowing& SKSNATURE <br /> Aut° Salvage, Inc wdl be held harmless by the undcrsrgncd from <br /> all claims of any nature arising from the removal of the vehicle INSURANCE CO. <br /> from any location, public or private <br /> POLICY ~F <br /> X AGENT <br /> I hove authorized F & M TOWING 8 AUTO SALVAGE INC. to tow my car and <br /> I hereby authorized my Insurance Com n to make a ment <br /> Pa Y P Y to this towing agency on <br /> my behalf. Am°°"t <br /> <br /> L Signature Date <br /> OWNER'S ~-j <br /> NAME ~ - I ~ {.i / ` 5;p/</ <br /> ~1 F <br /> ADDRESS t~' i..J~ ~ ~r. :rt 3r \ ~1.~ \ i~ ~ lJ <br /> <br />