Dri-Tech Authorization Leak Form

Date *

Date

Warranty Call? *

Name of Business (Where leak is located) *

Job Address *

Street Address

Suite #

City State / Province

Postal / Zip Code

Hours of Operations *

Point of contact *

First Name Last Name

Phone Number *

Roof Access Information (Bring ladder, Pick up key/location, Combo, etc.... *

Upload Photos

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Description of Leak *

Billing Company Name: *

Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

PO # (if available)

Requested By: *

First Name Last Name

Phone Number *

Please enter a valid phone number.

E-mail *

example@example.com

Billing Information:
This authorization covers Service Call & 1st hour service of $300.00. Additional time of $180.00 per hour with a DO NOT EXCEED $660.00 without additional authorization. Net 15 days upon invoice. NO RETENTION. Interest rate of 1.5% weekly will apply on unpaid balance after 15 days from date of invoice.

Agree to Billing Information *

Signature *

Clear

Name *

First Name Last Name

Dri-Tech Leak Authorization Form