Service Request Form

Service Request Form

Mechanics of Faith
Location: 8133 Mechanicsville Trnpke, Mechanicsville Va 23111

Please fill in the form below:
Driver Information
Driver's Name*

First NameLast Name
Phone Number*
Email
example@example.com
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
If you are unable to upload, please bring these items on the day of service to our front desk.
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

Clear
Date Signed

MonthDayYear
Date
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.

If you are unable to upload, please bring these items on the day of service to our front desk.