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43 South Skiview Drive

Beloit, Wisconsin 53511


( ) Lockout ( ) Jump Start ( ) Tow

I, the undersigned, in consideration of Scofield's Towing providing the service requested above, hereby release,
indemnify, and hold harmless Scofield's Towing and its employees, from all claims, demands, actions, and causes
of action of every nature, including those relating to negligent acts, and including, but not limited to, all losses or
expenses that may arise and relate in any way to the actions of Scofield's Towing, its employees, or agents
pursuant to the companies provision of such services. I understand that such service involves the risk of damage to
my vehicle and expressly accept the risk of any and all such damages.

Your signature below indicates that the Scofield's Towing Company and its employee's are released from any
liability resulting from our attempt to unlock your vehicle or start your vehicle (via a battery jump-start) or tow your
vehicle. Your signature affixed to this document is testimony that you have read and understand this statement and
have no questions.

IMPORTANT: You are advised that newer model vehicles are designed to make any attempt to unlock the door
without the proper key a most difficult task. Scofield's Towing employees have been instructed to assist you by the
use of special tools. However, there is no guarantee that access will be gained. Also, there is a chance that damage
may occur in the attempt to gain access to your vehicle.

Date; Owner's Name

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Drivers Lic. #

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