AUTHORIZATION FOR AUTOMOTIVE KEY GENERATION and/or IMMOBILIZER SYSTEM/ANTI-THEFT SERVICES

(The LSID Holder must fill out this form, after personally looking at the photo I.D., the registration and the VIN plate on the Vehicle.

These forms are to be kept for 2 years in a secured location as per the NASTF positive I.D. Policy. The NASTF Director of Operations will randomly audit these forms to ensure compliance with positive I.D policy. Failure to produce D-1 Forms when requested will result in LSID registry suspension and possible termination.)

I hereby certify that I have the authority to order keys and immobilizer system reset services for the vehicle indicated below. I agree that the information I am providing is true and correct. Further, to the maximum extent permitted by applicable law, I agree to indemnify and hold harmless the service provider listed below and related parties providing security information from any and a liability or claims that may arise from the performance of this service. I further agree to indemnify the automaker and their affiliates, successors, assignees, and nominees from any and all claims, losses, or costs (including reasonable attorney's fees) arising from any acts or omissions of the service provider, the service provider's employees, subcontractors, or agents.

Vehicle Owner/Customer Name:                                                                                                                                                              Address:                                                                                                                                                                                                        City / State / Zip Code:                                                                                                                                                                                       Telephone:                                                                                                                                                                                                    

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Vehicle Owner/Customer Signature                                                                                               Date

Driver’s License Number ¹                                                       State                                                        Expiration Date

Other Form of ID (specify type and number):                                                                                                                                                   

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Vehicle Year                                           Make                                                       Model                                                      Color:

Odometer Reading (mileage):                                                                                     (or)  Not Available: 🞏

For Dealership/Auctions:         PO / Stock #                                                            /

Service Performed:                  🞏 Key cut from code      🞏 Immobilizer reset        🞏 Other (describe below):

VSP/Service Provider Business Name:

iKeyless, LLC d.b.a Car Keys Express

Phone:     502-442-2380                                                                                                                               

Address:     828 East Market Street                                                                                                              

City / State / Zip Code:     Louisville, KY 40206                                                                                                     

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 VSP/Technician Name                                                                                                                                                      LSID: 

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 VSP/Technician Signature 

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Contracting Shop Owner/Manager Signature                                                                                                                         Date 

(Item 8 of the PositiveID Policy)

¹ IMPORTANT: Mobile Service Providers- If the VSP is not present at the time vehicle is received for service by a contracting service facility, the contracting service facility must make a photocopy of the vehicle owner’s driver’s license and attach to this form. Additionally, a valid registration must be left with the vehicle so that the VSP can verify that the driver’s license matches the ownership documentation.

DCDB01 20874833.4 v1.2 21-Nov 11                                                                                   Page 2 of 2