DRS Printable Order Form

Client Information

Lien Holder:
Account#:
Assignment Type:
Address:
City:
State:
Zip:
Attention:
Title:
Phone:	Ext:
Fax:
E-mail:

Debtor Information

Debtor:
Address:
City:
State:
Zip:
Home Phone:
Work:
SS#:
DOB:

Employer:
Address:
City:
State:
Zip:
Phone:
Employment Verified:
Shift:	Day Evening Night

Co/Debtor:
Address:
City:
State:
Zip:
Home Phone:
Work:
SS#:
DOB:

Vehicle Description

Vehicle: Year
Vehicle: Make
Vehicle: Model
Vehicle Identification Number:	Make sure to include all seventeen (17) numbers/letters!
Color:
Tag:
State:
No. of Doors:
Mileage:
Key Code(s):

Loan Information

No. of Payments Due:
Payment Amount:
Amount Due Now:
Due Date:
Loan Balance:
Contract Date:

Please add any information you have in regards to co-signer, family
members, relatives of the debtor, or any unique or defining information that
would be helpful in aiding us in the recovery of your collateral, please enter
that information in the space below.

Please provide special instructions in this space:

This is your authorization to allow DRS to act as your agent to collect or repossess the above named collateral. DRS agrees to indemnify and hold you harmless from and/or against any and all claims, damages, losses and actions including reasonable attorney fees, resulting from and/or 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.

Authorized by: Date: