Glass RX Windshield Repair (601) 494-1369

Rock Chip Repair Waiver

Please read the terms below and sign in the presence of your Glass RX technician before your windshield rock chip repair begins.

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I have read and agree to the terms above.

Printed name

Vehicle (year / make / model)

Signature

Date

Windshield tinted? (Yes / No)

Glass RX technician

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