PAYLESS CAR KEYS CORP.

KEY CUTTING AND MODULE PROGRAMMING AUTHORIZATION FORM

Key cutting and module programming authorization

I, _____________________________________ registered owner of this vehicle:

Make: ___________________________________________________________

Model: __________________________________________________________

Year: ____________________________________________________________

Vin: _____________________________________________________________

I, authorize Payless Car Keys Corp.

To make a key by the door lock cylinder and (or) program key by the module and
(or) repair my damaged module.

I, understand that module programming service involves reading and in some

cases writing memory of the module and the key will be programmed directly to
the memory of the module.

I am aware that this service might not fix problems related to the electrical
issues or damaged data inside the module.

I, agree that Payless Car Keys Corp take no responsibility for damaged or
corrupted data in the memory of the module of your car.

________________________________________ ____________________

Name Date

Return shipping address:

My contact information:

Telephone: email address:

2035 VICTORY BLVD, STATEN ISLAND, NY 10314

T (718) 907-3000 U PAYLESSCARKEYS.COM