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

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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

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)

Sign inside the box above.

Invoice / Receipt Photos (take a picture)0/6

Photos are attached to this ticket's PDF and emailed with it.

Submitting will assign invoice #… and email the completed ticket to frank@heavyrepair.com and tyler@heavyrepair.com.