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Name ______________________________________________________________

Home  (___)_____-_______        Address _________________________________

Work   (___)_____-_______                       _________________________________

Mobile (___)_____-_______                      _________________________________

Appointment Scheduled?  Yes   No

Requested Time To Have Ready ________

Symptoms or Work To Be Performed:

__________________________________________________________________

 

 

I VOLUNTARILY REQUEST DENNY’S AUTO DIAGNOSIS PROVIDE DIAGNOSIS, SERVICE, AND OR REPAIR TO THE BELOW DESCRIBED MOTOR VEHICLE.

BY SIGNING THIS FORM, I APPROVE COSTS NOT to EXCEED $___________. 00*  WITHOUT MY APPROVAL.  *Include enough for diagnosis!

 

DENNY’S AUTO IS NOT RESPONSIBLE FOR THEFT OR VANDALISM

to VEHICLES LEFT ON OUR LOT – please remove all valuables!

 

 

YEAR _______   MAKE __________________________  MODEL _______________________________________

 

 

SIGNATURE ___________________________                          DATE                TIME               

 

 

NOTE:  MICHIGAN BUREAU OF AUTOMOTIVE REGULATION REQUIRES FORM TO BE COMPLETE WITH SIGNATURE BEFORE ANY WORK IS PERFORMED.



 


      

 
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