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2. Name of Property Owner/Agent*
4. Property Name*
6. Address*
8. City*
9. State*
10. Zip Code*
14. Individuals authorized to initiate non-consensual tows
16. Full Name
17. Phone Number
18. Email
20. Full Name
21. Phone Number
22. Email
24. Full Name
25. Phone Number
26. Email
28. Full Name
29. Phone Number
30. Email
32. Full Name
33. Phone Number
34. Email
36. Full Name
37. Phone Number
38. Email
40. Full Name
41. Phone Number
42. Email
44. Full Name
45. Phone Number
46. Email
48. Full Name
49. Phone Number
50. Email
52. Full Name
53. Phone Number
54. Email
58. I, the property owner/agent of the above listed location, grant permission to those listed above to remove motor vehicles from this designated private property without the vehicle owner’s consent. This agreement shall remain in effect from date below until changed by property owner/agent.
60. Agent of record means the person that a property owner has given authority to authorize a wrecker business to tow from their property by submitting an authorization form to the public safety department naming said person(s). The agent of record may not be any employee or agent of any towing business.
62. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature*
66. Date*
    Date
67. Phone Number*
Leave This Blank:


69. Submit

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