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HEAVY DUTY TRUCK SERVICES

Repair Shop # 7130793

Commercial Roadside / Towing Permit Holder for NYS Thruway System

889 US Highway 6, Port Jervis, NY 12771

All Hours (845) 734-1300 · Fax (845) 697-8400

service@nysheavyrepair.com · www.heavyrepair.com

Mastercard · Visa · American Express · Discover · Comchek

INVOICE
—
Auto-assigned on submit
DATE *
EVENT #
THRUWAY TRUCK #
COMPANY NAME *
UNIT #
YEAR
MAKE
MODEL
COLOR
LICENSE
STATE
MILEAGE
VIN (17 CHARS)
TIME OUT
MILEAGE OUT
TIME IN
MILEAGE IN
MECHANIC'S SIGNATURE (TYPE FULL NAME) *
AUTHORIZED SIGNATURE (TYPE FULL NAME)
MILEAGE CHARGE Miles × Rate
@=
LABOR CHARGE Hours × Rate
@=
TOW CHARGE
ROAD SERVICE CHARGE
PARTS CHARGE
TOLL CHARGE Count × Rate
@=
SUB TOTAL
TAX
TOTAL *
ROADSIDE INFORMATION — BREAKDOWN LOCATION
COMPANY NAME
STREET ADDRESS
CITY
STATE
ZIP
NAME OF DRIVER *
DRIVER'S NUMBER
TRUCK ISSUE *
MILE MARKER
WORK COMPLETED
PARTS USED
PRICE
BILLING / PAYMENT INFORMATION
CREDIT CARD
REF #
OTHER PAYMENT METHODS
CC #
BILLING ZIP
EXP DATE
SEC #
NAME ON CARD
EMAIL TO SEND BILL TO
DRIVER SIGN-OFF & ATTACHMENTS

Driver's signature (sign with finger or stylus)

INVOICE / RECEIPT PHOTOS (TAKE A PICTURE) — 0/6
Photos are stored with this ticket and linked in the email.

Submitting will assign invoice #— and email the completed ticket to frank@heavyrepair.com and tyler@heavyrepair.com — and file it in the shop system automatically.