Dri-Tech Authorization Leak Form

Date*

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....*

Upload Photos

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Description of Leak*

Billing Company Name:*

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 $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 NameLast Name

Dri-Tech Leak Authorization Form