Dri-Tech Authorization Leak Form

Dri-Tech Leak Authorization Form
Date*

MonthDayYear
Date
Warranty Call?*
Name of Business (Where leak is located)*
Job Address*

Street Address

Suite #

CityState / Province

Postal / Zip Code
Hours of Operations*
Weekend Hours? (Time)
Point of contact*

First NameLast Name
Phone Number*
Roof Access Information (Bring ladder, Pick up key/location, Combo, etc....*
Description of Leak*
Upload Photos

Cancelof
Company Name:*
Billing Entity:*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PO # (if available)
Requested By:*

First NameLast 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 $360.00. Additional time of $180.00 per hour with a DO NOT EXCEED $500.00 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 NameLast Name
Should be Empty:

Dri-Tech Leak Authorization Form