Service Request Form

Service Request Form

Mechanics of Faith
Location: 102 Sharon Road, King William VA 23086

New clients, please fill in this form. Please understand our staff works extremely hard to get back to applications in a timely manner, but we are incredibly busy and there might be delays of several days to several weeks before you hear from us to schedule your vehicle for service. We typically reply to applications on Tuesdays and Thursdays.

If you are a returning client, please utilize our returning client form or give us a call to schedule your appointment.
Driver Information
Driver's Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently living in your vehicle.

YESNO
Care Partner (If Applicable)
Optional
Marital Status

MarriedSingleDivorceSeparatedWidowed
Gender

MaleFemaleOther
Ethnicity

Hispanic/LatinoBlack/African AmericanNative Hawaiin/Other Pacific IslanderAmerican Indian/Alaska NativeAsianWhite
How did you hear about us

WebsiteSocial MediaFriendOther
Number of household members
Household yearly Income
Employment Status

EmployedUnemployedContractor (Self Employed / Door Dash/ Uber)
Car Details
Year*
Make*
Model*
License Plate Number*
Color of Vehicle*
VIN (can be found on registration or on vehicle near the bottom left windshield)*
If you need something not listed below, please explain as we offer many services not listed below.
Service Needs (If known, these are not all our services)

Oil ChangeTire RotationBrakesRotorsBatteryOther (Example:Starters,Alternator,Engine or transmission)
If Other, please explain
If you are unsure of the repairs your car made need please just type diagnostic
To receive automotive repair at Mechanics of Faith, you must receive government assistance or referred to us via a community partner.
Check this box if you will supply the below information upon arriving for service.

Provide Document at time of service
SNAP/Medicaid (Documentation)

Cancelof
Vehicle Registration (Documentation)

Cancelof
Driver's License (Front Only)

Cancelof
Covenants*

I understand that if my vehicle is not removed from the property after 5 days of notification of repairs completed or unable to be completed a $10.00 per day storage fee will be applied for each day, after 30 Days vehicle may be subject to impoundI understand that I will be responsible for parts & program fees at time of service.
Driver's Signature or 3rd Party*

Clear
Date Signed*

MonthDayYear
Date
If a 3rd Party is filling our this form on the behalf of the client please provide the below data.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Mechanics of Faith helps anyone in need that meets our guidelines regardless of race/ ethnicity, religion, or gender.
Should be Empty:

Service Request Form

Driver Information

Car Details

If you need something not listed below, please explain as we offer many services not listed below.

To receive automotive repair at Mechanics of Faith, you must receive government assistance or referred to us via a community partner.

If a 3rd Party is filling our this form on the behalf of the client please provide the below data.