TIME & MATERIAL SERVICE REQUEST FORM

TIME & MATERIAL SERVICE REQUEST FORM
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Please provide the billing information below
Company Name*
Contact Name*
Phone Number*
Format: (000) 000-0000.
Invoice Email Address*
Street*
City*
State*
Zip Code*
JOB SITE INFORMATION

Please provide information for the job site below
NoYes
Job Site Name*
Street*
City*
State*
Zip Code*
APPOINTMENT INFORMATION & ON-SITE CONTACT:

Please provide information for the appointment and on-site contact below
Preferred Arrival Window*
(Example: 5am - 5pm)
On-Site Contact Name*
On-Site Contact Number*
Format: (000) 000-0000.
On-Site Contact Email*
Reason for work request / repairs*
EEHI service terms on a Time and Material Basis are as follows:
- Minimum Trip charge for mobilization work / diagnosis of issue is $850 (covers up to 3 hours of work)
- Rate after first 3 hours: $135 per hour, per technician, minimum 2 technicians
- Material cost will carry a 40% handling fee
- Terms of payment, due upon receipt of invoice
- All invoices sent electronically to billing contact information above
- If a Certificate of Insurance is required, this must be requested at or before the time of service call
By signing below, I acknowledge and agree to pay Elson Electric Holdings, Inc. on a Time & Materials basis for the labor and materials incurred to complete the service work.
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Date:*
1330 N Broadway, Suite 202, Walnut Creek, CA. 94596 — (925) 420-5076 - Lic. #1045018
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