Date___________________

Name_______________________________________________________

Address_____________________________________________________

City________________________State________Zip__________________

Phone______________________________Email____________________

Vehicle Year/Make/Model________________________________________

Comments:_____________________________________________________

______________________________________________________________

______________________________________________________________

Credit card info (Pre-pay only if you will pick up after hours) Name if different from above:

____________________________________ V/MC/AMEX/Discover (circle)

Card Number______________________________________________Exp. _________

CSV____________ Amount: $__________

I hereby authorize the above work, including any equipment and any necessary materials. Roberts Mobile Electronics and its employees may operate this vehicle for the purpose of installation, testing, inspection, and delivery at my risk. An express mechanic's lien is acknowledged on this vehicle to secure work and/or materials, and my vehicle will not be returned until full payment has been made. I agree that if I supply defective equipment for installation that was not purchased at Roberts Mobile Electronics, I will still be responsible for all installation charges. Roberts Mobile Electronics will not be liable for loss or damage resulting from the following causes: a) fire; b) theft of vehicle or of its contents; c) age or condition of the vehicle. I acknowledge that older vehicle parts can be damaged from heat, sunlight, and normal wear and tear. I agree that Roberts Mobile Electronics will not be liable for damage to my vehicle's parts weakened by such effects. Insurance against any loss from such an occurrence will be my responsibility.


Signature:______________________________________________________________
Roberts Mobile Electronics & Enhancements
11704 Shelbyville Road
Louisville, KY 40243