Advanced Auto Service, Inc.

Debtor Information:
Debtors Name:		Spouse's Name:
Home Address:		Spouse's DOB:
Home Phone:		Spouse's SS #:
Employer:
Work Address:
Work Phone:
DOB:
SIN #:

Collateral Property Information:
Year:		Make:
Model:		Color:
License #:		State:
Ignition Key #:		Trunk Key #:
VIN #:

Loan Information:
Loan Number:		Balance:
Past Due Date:		Monthly Payment:
Past Due Amount:
Assignment Type:

This is your authorization to act as our agent to collect or repossess the
above collateral. We agree to indemnify and hold you harmless from and
against any and all claims, damages, losses and actions including reasonable
attorney fees, resulting from and arising out of your efforts to collect and
or repossess claims, except, however, as such may be caused by or arise out
of negligence or unauthorized acts on the part of you, your company, its
officers, employees or its agents.

Authorization:
Authorized By :		Date:

Any questions? Please contact us:

Phone: 800- 358-7376
Fax: 626-962-9973

You may also contact us via email: bill@repoguy.com