Concession Request Form

"*" indicates required fields

VIN #*

Vehicle License Plate*

Year*

Make*

Model*

Email*

Phone*

Address*

Street Address City State ZIP Code

Entity that Authorized the Tow*

(Name of the Property the Vehicle was Towed From)

Towing Company Name*

Vehicle Storage Facility Name*

For the sole consideration of*

(Enter Dollar Amount)

Date Vehicle Towed*

Driver's License Photo*

Please upload a clear photo of your driver's license.

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, heic, Max. file size: 6 MB.

Acknowledgement

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Concession Request Terms & Conditions

I have Read, Acknowledged, Agreed and Accepted the Terms & Conditions

I Have Read, Acknowledged, Agreed and Accepted the Terms & Conditions*

I Have Read, Acknowledged, Agreed and Accepted the Terms & Conditions.*

Vehicle Owner/Operator Signature*

I HAVE READ, ACKNOWLEDGED, AGREED AND ACCEPTED: Agreed terms and conditions of the settlement. I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Vehicle Owner/Operator (Must Match Signature)*

First Last

Today's Date*

CAPTCHA

Consumer Disclosure Regarding Signing Documents Electronically, Conducting Business Electronically, and Receiving Electronic Documents, Notices and Disclosures
By submitting this form, I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. By utilizing the electronic signature on this form, you are agreeing that you have reviewed the following information, and you consent to utilizing electronic signatures in lieu of using handwritten or non-digital signatures or paper, to conduct business using electronic communications, and to receive notices, signatures, and disclosures electronically. You are not required by us or by law to consent to any of these things. If you have consented to receive future electronic signature invitations or other notices, signatures, or disclosures electronically from us, and you want to withdraw that consent, you may email or call us. If you do not agree to utilize electronic signatures in lieu of using handwritten or non-digital signatures or paper, please email that us regarding this matter.

Your information is processed securely, and is never shared, distributed, or sold to any third parties. By providing a telephone number and submitting the form you are consenting to be contacted by voice or SMS text message. Message frequency may vary. Message & data rates may apply. Reply STOP to opt-out, Reply HELP for more information.

Name

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