Appointments and Pre Check-In Select Location* ADA GRAND RAPIDS Personal Information(*Required Fields)Customer Name*City/Zip*Cell#*Email (Required for Email Confirmation)Address*Work#Home#Vehicle InformationMake & Model*License Plate Number*Color*Initials*Your initials verifying repair concerns*Pre-Approval of Repairs/TestPre-Approval of Repairs/Test* $1,000 $500 $250 $100 $0 Just Fix It Completion RequestCompletion Date* MM slash DD slash YYYY Time of Day AM PM Please Initial for AuthorizationInitial*Are you the authorized decision maker for the vehicle?Initial*Note: Delayed communication will result in overall setbacksInitial*Note: Phone approvals for repairs and testing are bindingInitial*$20/fee begins Day 3 for : non-approved repairs or vehicle retrievalWould you like to OPT OUT of Veenstra's loyalty program? No Yes Description of ConcernsSign* Name I hereby authorize the repair work to be done along with the necessar y par ts and materials and hereby grant you and/or your employees permission to operate the vehicle herein described on streets, highways or elsewhere, at your discretion for the purpose of testing and/or inspection. An express mechanic lien is hereby acknowledged on the above vehicle to secure the amount of repairs thereto. I understand that Veenstra’s is not responsible for delay or other consequence due to the unavailability of par ts shipments beyond their control. Veenstra’s is not responsible for damage or ar ticles left in vehicle in case of fire, theft, vandalism, or any other cause beyond our control.Date MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged. Δ