PARTS / REPAIR FUNDING REQUEST

Please fill out the following form completely with attached invoice/quote from our partner company.

First name

Last name

Company

For what are you requesting funds?

On-Site Repair

Mobile Repair

Location

Phone

Driver's Name

Driver's Phone

Truck #

VIN # (Last Six)

Description of Maintenance Issue

Digital Signature

Today's Date

Terms and Conditions: By completing this form you are authorizing Kemet Advance to dispatch a mechanic and /or pay for said repairs on your behalf. The amount of the repair, plus a fee of 10% of the total cost of the repair, will be deducted from your upcoming paycheck issued from Kemet Solutions to satisfy the debt incurred. Neither Kemet Advance nor Kemet Solutions holds any responsibility or liability for any part(s), services or repairs related to this transaction, nor offers any warranty or guarantee for the repair work performed.

I agree to the terms and conditions stated above. I further assert that tinformation entered is true and accurate.

Thanks for submitting!