AGREEMENT FOR REPAIRS
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It is hereby agreed between _______________________ (Insert
name and address of vehicle owner or person in charge of disabled
vehicle authorized to enter agreement) and __________ (Insert name,
address, telephone number and license number of tow car owner and
name, address, telephone number of repairer) that __________ (vehicle
owner or person in charge) agrees to pay the sum of $ _____ to __________
(repairer) who in consideration thereof agrees to repair a __________
(year, make and type of automobile), New York State registration number
_____, which was involved in an accident or otherwise disabled and
removed by a tow car.
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Dated at _________________ this _____ day of __________, 20_____.
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Licensee ____________________
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Vehicle owner or person in charge (check appropriate one):
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TOWING AUTHORIZATION
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(Insert name, address, and phone number of tow car owner and
terminal)
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Date ____________________
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Name
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Address
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Make and type of car
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Year __________
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State registration number _________________
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Towed from _______________ to _______________.
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Number of miles towed: __________.
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Towing charges: _____ (amount shown on filed schedule, not to
exceed $125 for first mile or part thereof and $5 for each additional
mile or part thereof)
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Storage charges: _____ (amount shown on filed schedule, not
to exceed $25 per day.)
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Labor charges: (a) Right overturned vehicle or winch off-roadway:
$__________(amount shown on filed schedule, not to exceed $45 per
half-hour not to exceed a maximum charge of $90)
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(b) Recovery and extraction of a disabled vehicle from extreme
conditions (i.e., removal from water, off-road more than 50 feet from
pavement into wooded area, atop roadway dividers): $__________ (amount
shown on filed schedule, not to exceed $45 per half-hour).
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Method of payment (circle one): Cash/Visa/MasterCard/Discover/American
Express
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Tow car driver's name:
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Tow car owner:
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Terminal address:
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Tow car driver's license number: ______________
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Tow car's medallion number: ______________
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State registration number: ______________
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I authorize the towing of the above automobile:
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(Signature of vehicle owner or person in charge)
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TOW CAR OWNER NAME, ADDRESS, AND TELEPHONE NUMBER
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TOWN OF HEMPSTEAD TOW AUTHORIZATION AND TRIP
RECORD
FOR MOTOR VEHICLES REMOVED FROM A PRIVATE PARKING
LOT
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DATE OF REPORT:____________. DATE OF REMOVAL: ____________.
TIME OF FIRST OBSERVANCE OF IMPROPERLY OR UNAUTHORIZED
PARKED VEHICLE BY AGENT AUTHORIZED TO REQUEST REMOVAL: __________AM/PM
(MUST BE AT LEAST 15 MINUTES AFTER TIME NOTED ABOVE)
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TIME OF REMOVAL: _____ AM/PM
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LOCATION OF REMOVAL (FULL ADDRESS):
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TERMINAL ADDRESS:
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AUTHORIZED AGENT AT SCENE AUTHORIZING REMOVAL:
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______________________
______________________
NAME (PRINT) ORIGINAL
SIGNATURE
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TIME OF AUTHORIZATION: __________ AM/PM
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REMOVAL PURSUANT TO FILED CONTRACT BETWEEN:
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__________________________ AND __________________________
PROPERTY OWNER TOW
CAR OWNER
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PERSON EXECUTING REMOVAL (TOW CAR OWNER
OR TOW CAR DRIVER)
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NAME:
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T.O.H. LICENSE NUMBER: __________. TOW CAR MEDALLION
NUMBER: __________
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BUSINESS ADDRESS:
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VEHICLE INFORMATION:
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PLATE NUMBER: __________. REG. YEAR: __________. VEHICLE
YEAR: __________.
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MAKE: __________ MODEL: __________. BODY TYPE: __________.
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COLOR: __________. VIN NUMBER: __________.
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REGISTERED VEHICLE OWNER: NAME:
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ADDRESS:
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POLICE PRECINCT INFORMATION:
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NAME OF PERSON RECEIVING REPORT:
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PCT.#__________ DATE: __________ TIME: __________AM
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NAME AND SIGNATURE OF OWNER OF THE PRIVATE PARKING
LOT, OR HIS/HER AGENT SPECIFIED IN THE CURRENT FILED CONTRACT AGREEMENT
WHO IS ACTUALLY PRESENT IN SAID PRIVATE PARKING LOT AND REQUESTING
SEIZURE OR REMOVAL:
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______________________ ______________________
NAME SIGNATURE
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2 Copies:
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TOW CAR OWNER NAME
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1 For tow car owner
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TERMINAL ADDRESS
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1 For vehicle owner
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TELEPHONE NUMBER
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PRIVATE PARKING LOT TOW REMOVAL RECEIPT
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DATE OF REMOVAL: ________________
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TIME OF FIRST OBSERVANCE OF IMPROPERLY OR UNAUTHORIZED PARKED
VEHICLE BY AGENT AUTHORIZED TO REQUEST REMOVAL: __________AM/PM
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TIME OF REMOVAL: __________AM/PM (MUST BE AT LEAST 15 MINUTES
AFTER TIME NOTED ABOVE)
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VEHICLE INFORMATION:
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License Plate #: _________. State: _________. Year: _______.
Make: __________.
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Model: ______________.
VIN #: ______________
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TOWED FROM: (Insert Complete Name and Address of Private Parking
Lot)
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TERMINAL ADDRESS TOWED TO:
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MILEAGE TOWED:__________
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TOWN OF HEMPSTEAD RATES (ALL CHARGES MUST BE ITEMIZED)
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REMOVAL
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$125 (INCLUDES 1ST 3 DAYS STORAGE & MILEAGE)
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STORAGE
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$25 PER DAY THEREAFTER
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DROP FEE
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40% OF REMOVAL CHARGE(S) WHEN VEHICLE OPERATOR OR OWNER ARRIVES
PRIOR TO REMOVAL FROM SCENE
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SUB TOTAL
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SALES TAX
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TOTAL
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TOW CAR DRIVER: ________________ T.O.H. LIC. #_______
(Full
Name)
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PAYMENT RECEIVED BY: _____________ DATE: _______
(Signature)
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METHOD OF PAYMENT (Circle One): CASH/VISA/MASTERCARD/DISCOVER/American
Express
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I ACKNOWLEDGE THAT NO RELEASE OR WAIVER OF ANY KIND, WHICH
WOULD RELEASE THE TOW CAR DRIVER OR TOW CAR OWNER FROM LIABILITY FOR
DAMAGES MAY BE REQUIRED AS A CONDITION OF RELEASE OF THE ABOVE DESCRIBED
VEHICLE.
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SIGNATURE OF OWNER OR PERSON IN CHARGE OF SAID VEHICLE
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DATE
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TOW CAR DRIVER OR OWNER AND VEHICLE REDEEMER MUST SIGN
BOTH RECEIPTS
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