TIME & MATERIAL SERVICE REQUEST FORM

TIME & MATERIAL SERVICE REQUEST FORM
BILL TO

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
Is The Work At This Address?
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 $900 (Covers a 3hr. min.) (S.F/South Bay=$1200/4hr. min.)
- Rate after first 3 hours: $150 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.
Signature
Date:
1330 N Broadway, Suite 202, Walnut Creek, CA. 94596 — (925) 420-5076 - Lic. #1045018
Should be Empty:

BILL TO