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F & M Towing & Auto Salvage, Inc. <br />3001 Main Street W 6427 <br />Springfield, Oregon 97478 <br />Phone (541 74155615 a Toll Free 18 00-3 8 65 6 1 5 <br />24-HOUR TOWING oAE /Z-zop <br />J& <br />MAKE YEAR l LIC. NO. 112C <br />BODY TYPE ) V i l h STATE-,-) I e REG. NO, <br />DESCRIPTION OF CHARGE <br />$ AMOUNT <br />TOWED <br />FROM <br />' alt <br />I <br /> <br />TOWED <br />TO o <br />STORAGE <br />AT <br />RETOW <br />TO <br />FUSEES <br />OUTSIDE LABOR <br />& RECOVERY <br />DOLUE <br />AUTHORIZED TOW <br />e) <br />/ <br />TOTAL <br />The mMcnigned agree, janily artd scvaglly, le pig F & M Towing d Auto Sal. CHARGES <br />s <br />vaec. Ine. within Ihinv 1701 diva fremddm Mmrviee_ tM ammm m fmh .raw. <br />f(W.tbc.ie,s dexnibed annt. Idttnexl a the role o! 10x per annum from date, <br />shall also be paid The undesigned further agree, and tedcnnnd that F d M Totting & Auto Salvage. Inc. may lorwandthis ae,ounl to .hen <br />attomcys in agent fa' collection upon the evintion orhaid 50 days and in that event the uMcrugne 1 jointly and severally, agree to pay a laic <br />payment tavka charge or55.00. plux a,..able anumry's re, to b, fiat W by the coon in ca asuite ocaabn it innlinned to collect the whale <br />or pan orwfnhm/((pI,."nacy's foes nacja/y'm/Jqd by ap l/flromadecidonofal.ccun. <br />SIGNED <br />BY ___LL_ /Lll ~YA ' (l <br />x f271y or' . <br />ADDRESS <br />The undersigned agree, that F d M Towing d Auto Sali,age. Inc. <br />.hall not be hcld liable for darmge to the above dosciibod volt ele <br />or cqulpmw t. occurring during the removal or ttatopwt oauaed by <br />the position, location orcandilion ofthc vehicle. Fd MTowing d <br />Auto Savage Inc. will be held ham" by the undenived from <br />all claims of any mlure atlsing Fran the retnov it of the vehicle <br />from any location, public ar private. <br />INSURED'S <br />SIGNATURE <br />INSURANCE <br />I. have authorized f & M TOWING & AUTO SALVAGE INC. to tow my car and <br />I hereby authorized my Insurance Company to make payment lat is lowing agency on <br />my behalf. _ A'"c'v" <br />Signature Dole <br />OWNER'S <br />NAME <br />