Scofield's Towing Inc.

Service Provider# 608-921-0726 Driver /

Date / Time / AM / PM / ETA /
Club /ect./ Membership #
PO#ect. Coverage limit /
Vehicle Description /
Located at /

Deliver to /

Passengers / 1 / 2 / $
Miles to / / minus miles/ actual / $
Miles loaded / / minus miles/ actual / $
Towing / Load up, Unload Charge $
Jump start / Unlock / Fuel / Flat / Air / GOA / wheel-lift / $
Winch / Time on job by the 1/2 hour min. $
Waiting on Police / Report # $
Clean up accident scene / Time / $
Extra Equip. / Skates / Dollies / Boards / Soap / $
Administrative Fee / Storage fee/ $
I agree to hold Scofield's Towing Inc. & its employee's Subtotal $
harmless for any damage's due to services rendered,
and will pay the listed charges for services rendered, Tax $
minus any accepted motorclub coverage, in full at that
time, before vehicle is unloaded, or vehicle will be held Total $
for listed charges, plus storage charges, that may Payment is cash,
accrue, & charges of theft of services will be filed. This MasterCard, & Visa
must be signed before work will start. only.
Accepted by: Customer /

Phone #
Address / State
Vehicle Lic. # State
Driver Lic.# State
Vin #