POV's Via LAX - Limited Power of Attorney And Service Agreement

Last Name_____________________________

First Name_____________________MI_____

SSN (Last 4 Digits)___________________

Rank/Grade____________________________

Address_______________________________

City__________________________________

State_________________Zip_____________

Vehicle Year_____Make_________________

Model_________________Color___________

Plate_________________________________

State/Country_________________________

ID____________________________________

Pick Up From [ ]LA VPC [ ]Matson

[ ]Horizon [ ]OpLift [ ]Other

(name_________________________________

phone________________________________)

Deliver to [ ]LAX [ ]Other

(location_____________________________

phone________________________________)

Shipped From__________________________

[ ]Military [ ]Private

Shipping / Order #____________________

RDD___________________________________

Arrive At [ ]LAX

[ ]Other (Airport____________________)

Date_________________Time_____________

Airline__________________Flight_______

Service Fee $_________________________

Plus $________________________ for gas

[ ]Premium [ ]Regular

[ ]Other______________________________

[ ]Cashier's Check

[ ]Money Order #____________________

Final Emergency Contact Information

______________________________________

______________________________________

______________________________________

______________________________________

POV PICK-UP INFORMATION AND AGREEMENT
PLEASE ACKNOWLEDGE WITH YOUR INITIALS WHERE INDICATED BY [ ]

PVL will acknowledge by mail, or FAX me at _________________________, the receipt of my order. If I do not receive my confirmation within ten days, I will contact PVL. My POV will be delivered to the said location up to TWO days [ ] prior to my arrival. PVL will notify me of any problems at my given emergency number [ ]. PVL will not be responsible for mechanical, electrical, tire failures, or glass damage during delivery, or damages before pickup at the port [ ]. PVL will check the vehicle against the Condition Report, and make any necessary annotations with port personnel. In case of an accident, PVL will pay my insurance deductible up to $500 [ ]. My insurance carrier is ______________________policy___________________. I will inspect my vehicle before leaving the parking lot [ ]. If I find damages or missing items not marked on the port's report, I will call PVL (818-766-6983) from the parking lot [ ]. PVL will not be responsible for damage information after my vehicle has left the lot [ ]. PVL is not responsible for demurrage, parking, storage, or any other incurred fees [ ].

Date ____________ Signature ________________________________

Note: Documents for POV pick-up from Horizon, LA VPC, & Matson need not be notarized.

LIMITED POWER OF ATTORNEY FOR VEHICLE PICK-UP PLEASE PRINT LEGIBLY

LIMITED POWER OF ATTORNEY FOR VEHICLE PICK-UP
PLEASE PRINT LEGIBLY