FLORIDA DEPARTMENT OF AGRICULTURE & CONSUMER SERVICES
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|PLEASE READ CAREFULLY, CHECK ONE OF THE |ABC AUTO REPAIR SHOP |_____month/________mile warranty |
|STATEMENTS BELOW, AND SIGN: |123 ANY STREET |on all parts and labor unless |
|I UNDERSTAND THAT, UNDER STATE LAW, I AM |ANY PLACE, FL 33333 |otherwise specified. |
|ENTITLED TO A WRITTEN ESTIMATE IF MY FINAL BILL |(123) 456-7890 | |
|WILL EXCEED $100. |****SAMPLE **** | |
|_____I REQUEST A WRITTEN ESTIMATE. |FLORIDA REGISTRATION: MV- 00000 | |
|_____I DO NOT REQUEST A WRITTEN ESTIMATE AS LONG AS THE REPAIR COSTS DO NOT EXCEED $_______. | | |
|THE SHOP MAY NOT EXCEED THIS AMOUNT WITHOUT | | |
|MY WRITTEN OR ORAL APPROVAL. | | |
|_____I DO NOT REQUEST A WRITTEN ESTIMATE. | | |
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|SIGNED _______________________ DATE ____________ | | |
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| | |Intended Payment Method: |
| | |CASH ? CHECK ? VISA ? MC ? AMEX ? |
| | |Date: Time: |
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| |Name: |Proposed Completion Date: |
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| |Address: |Home Ph: | |
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| |City: State: Zip: |Work Ph: | |
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| |Other Authorized Person: |Phone: | |
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| |Year/Make: |Model: |Tag: |Miles In: |
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| |VIN# : |Miles Out: |
| *U/Used R/Rebuilt RC/Reconditioned NC/ No Chg/Warranty RD/Reduced/ | |
| |Save Old Parts: ? Yes ? No (Core may apply) |
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|QTY |PART NO |DESCRIPTION |* |PRICE |EXTEND |Customer Complaint/Problem: |
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| | | | | | |LABOR CHARGES BASED ON: |ESTIMATE/DIAGNOSTIC FEE: |
| | | | | | |? FLAT RATE ? HOURLY RATE |$ /OR HOURLY AT |
| | | | | | |? BOTH APPLY |$ PER HOUR |
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| | | | | | |A storage fee of $ per day may be applied to vehicles which are not claimed within 3 working days of |
| | | | | | |notification of completion |
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| | | |Subtotal:$ |
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| | | |Tax: $ |
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| |**This charge represents costs and profits to the motor vehicle repair facility for |TOTAL: |
| |miscellaneous shop supplies or waste disposal. ***FS403.718 mandates a $1.00 fee for each|$ |
| |new tire sold in the State of Florida. ***FS403.7185 mandates a $1.50 fee for each new | |
| |or remanufactured battery sold in the State of Florida. | |
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