Rasch Express  ::  11207 Manchester Road  ::  Kirwood, MO 63122  ::  314-821-9920

After Hours Drop Off Form

Please complete this form, print it out and sign it, and place it and your car key in an envelope and drop it in our Night Drop Box. Thank you!

Personal Information
Name *
Address *
City * State * Zip *
Main Phone * Secondary Cell
What is the best time for us to contact you tomorrow, at what number?
  *

Vehicle Information
Year * Make * Model *
Color * Plate # *

Maintenance Service Requested (Check all that apply)
  State Inspection Tire Rotation Oil Change
  Balance Tires Brake Flush Coolant Flush
  Steering Flush Trans Flush Air Conditioner
  Wheel Alignment Tire Repair Other
If you checked "other", please explain.
 

Authorization

I hereby authorize the above repair work to be done along with the necessary material. I hereby grant you and/or your employees permission to operate the car, truck, or vehicle herein described on streets, highways, or elsewhere for the purpose of testing and/or inspection. An express mechanic's lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto:

Signature * Date *