All State Auto Delivery - Auto Delivery POA And Service Agreement

PLEASE PRINT LEGIBLY

Last Name ________________________
First Name _______________ MI_____
SSN_______________________________
Rank/Grade________________________
Address___________________________
City______________________________
State___________Zip_______________

Vehicle Year______Make____________
Model_____________Color___________
Plate_____________________________
State/Country_____________________
ID________________________________

Pick Up From [ ]LA VPC [ ]Matson
[ ]Horizon [ ]OpLift [ ]Other
(name_____________________________
phone____________________________)

Deliver to [ ]LAX [ ]Other
(location_________________________
phone____________________________)

Shipped From______________________
[ ]Military [ ]Private
Booking Or Order #________________
RDD_______________________________

Arrive At [ ]LAX
[ ]Other (Airport________________)
Date_______________Time___________
Airline______________Flight_______

Service Fee $______
Plus $_____ For Gas
[ ]premium [ ]regular
[ ]Other _________________________
[ ] Cashier's Check
[ ] Money Order #________________

Final Emergency Contact Information
__________________________________
__________________________________
__________________________________

Date_______Signature______________

POV PICK-UP INFORMATION AND AGREEMENT
PLEASE ACKNOWLEDGE WITH YOUR INITIALS WHERE INDICATED BY [ ]

ASAD will acknowledge by mail, or FAX me at _________________________, the receipt of my order. If I do not receive my confirmation within ten days, I will contact ASAD. My POV will be delivered to the said location up to TWO days [ ] prior to my arrival. ASAD will notify me of any problems at my given emergency number [ ]. ASAD will not be responsible for mechanical, electrical, tire failures, or glass damage during delivery, or damages before pickup at the port [ ]. ASAD will check the vehicle against the Condition Report, and make any necessary annotations with port personnel. In case of an accident, ASAD will pay my insurance deductible up to $500 [ ]. My insurance carrier is ______________________policy___________________. I will inspect my vehicle before leaving the parking lot [ ]. If I find damages or missing items not marked on the port's report, I will call ASAD (818-766-6983)from the parking lot [ ]. ASAD will not be responsible for damage information after my vehicle has left the lot [ ]. ASAD is not responsible for demurrage, parking, storage, or any other incurred fees [ ].

Date ____________ Signature ________________________________

Note : Documents for POV pick-up from Horizon, LA VPC, & Matson need notbe notarized.

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All State Auto Delivery, Inc.