Service Request Form

Service Request Form

Mechanics of Faith
Location: 6229 Osborne Trnpk, Richmond Va

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

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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
Car Details
Make*
Model*
Year*
License Plate Number
Car Color
Requested Service*
SNAP/Medicaid (Front Only)

Browse Files

Cancelof
Driver's License (Front Only)

Browse Files

Cancelof
Release & Agreement

I understand that Mechanics of Faith is not responsible for my vehicle after hours. I understand that the services being provided are provided by the volunteers with Mechanics of Faith. All volunteers performing repairs are immune from liability under the Good Samaritan Law. I hereby voluntarily consent to having my vehicle repaired.
Covenants*

I have read and understand the Release AgreementI understand that if my vehicle is not removed from the property after 5 days of notification my vehicle is subject to towI understand there will be program fee for repairs
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

Release & Agreement