Tow Control No. ____________________
DATE: ____________
Tow Crane No. _____________________
TIME: ____________
Tow Truck Service Receipt
____________________________________________________________________
LICENSEE NAME
____________________________________________________________________
TRADE NAME
____________________________________________________________________
PRIMARY BUSINESS ADDRESS
____________________________________________________________________
BUSINESS PRIMARY TELEPHONE NUMBER
Storage facility/repair location__________________________________________ Telephone # (___) _______________
Name of Customer: ________________________________________________________________________________
Customer Address: _________________________________________________ Telephone # (___) _______________
Tow Pick up Location: _________________________________________________
_________________________
Street Location
City and State
Tow Delivery Location: _________________________________________________
_________________________
Street Location
City and State
Description of Disabled Vehicle
Color: ______________ Make: ____________Model ____________Year ________________Tag No.: ____________
State of Vehicle Registration: ___________________________ Vehicle towed to: ______________________________
Schedule of Towing Fees
Public Tow (whether accident or impound) $
Public Storage Service Fee: $
Private Tow
From Accident:
Minimum: $______________________
Maximum: $_______________________
Non-Accident:
Minimum: $______________________
Maximum: $_______________________
Total Towing Fees Due:
$________________________________
Daily Storage Fees:
Minimum: $______________________
*Maximum: $_______________________
(*Maximum rate per 24 hour period or part thereof, which period shall start when the vehicle enters the tow service storage lot to which the vehicle is
towed.)
OTHER CHARGES/DESCRIPTIONS: _________________________________________________________________
________________________________________________________________________________________________
Name of Tow Truck Operator: (Print)
Signature____________________________
Signature (Disabled Vehicle Operator): _________________________________________________________________
NOTE: Licensee must retain a copy of the receipt for a period of three years.