We are pleased you have selected the services of Jefferson Fire & Safety, Inc. Before we can proceed, we request that you complete the following information form. Thank you for your time and we look forward to doing business with you!
Your Business Information
Business Name
*
Contact Person Name
*
First Name
Last Name
Contact Person Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Accounts Payable Contact Person Name
*
First Name
Last Name
Accounts Payable Contact Person Email Address
*
example@example.com
Accounts Payable Contact Phone Number
*
Please enter a valid phone number.
AP Contact Person Email
Please enter a valid phone number.
Back
Next
BILLING INFORMATION
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Email - Enter your billing email address if you want to receive invoices via email.
example@example.com
Back
Next
SERVICE ADDRESS
Enter the address where service(s) will take place.
Primary Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Multiple Service Addresses
*
Yes
No
Back
Next
TRADE REFERENCES
Please list 3 trade references.
Trade Reference #1
*
Include contact name, company name, & telephone number
Trade Reference #2
Include contact name, company name, & telephone number
Trade Reference #3
Include contact name, company name, & telephone number
Back
Next
BANK REFERENCE INFORMATION
Please provide the banking reference information requested below. DO NOT INCLUDE ANY ACCOUNT #'s OR SENSITIVE INFORMATION.
Bank Name
*
Bank Contact Person
*
First Name
Last Name
Bank Phone Number
*
Please enter a valid phone number.
Tax Exempt - Does your business have tax-exempt status?
*
Yes
No
Tax Exempt # - Enter your Tax Exempt # if applicable.
Back
Next
FIRE EXTINGUISHER SERVICES
In the next few questions, you will select which services will be required by your business including; fire extinguishers, fire suppression systems, fire alarms, exit/emergency lighting, and fire doors.
FIRE EXTINGUISHERS: Would you like your business set up on an ANNUAL basis? (Per NFPA 10 and Local Fire Code) Special circumstances? Use OTHER and explain.
*
Yes - Enter the next required service date below.
Not interested in this service
Other - Special Circumstances
If you answered OTHER, please explain the special circumstances.
If you answered YES or OTHER, enter the date when your next service is required. Skip if you answered NOT INTERESTED.
-
Month
-
Day
Year
Date
Back
Next
FIRE SUPPRESSION SYSTEMS
FIRE SUPPRESSION SYSTEMS: Would you like your business set up on an SEMI-ANNUAL basis? (Per State & Local codes) Special circumstances? Use OTHER and explain.
*
Yes - Enter the next required service date below.
Not interested in this service
Other - Special Circumstances
If you answered OTHER, please explain the special circumstances.
If you answered YES or OTHER, enter the date when your next service is required. Skip if you answered NOT INTERESTED.
-
Month
-
Day
Year
Date
Back
Next
FIRE ALARM SYSTEM SERVICES
FIRE ALARM SYSTEMS: Would you like your business set up on an ANNUAL basis? (Per NFPA 72 and Local Fire Codes) Special circumstances? Use OTHER and explain.
*
Yes - Enter the next required service date below.
Not interested in this service
Other - Special Circumstances
If you answered OTHER, please explain the special circumstances.
If you answered YES or OTHER, enter the date when your next service is required. Skip if you answered NOT INTERESTED.
-
Month
-
Day
Year
Date
Back
Next
EXIT/EMERGENCY LIGHTING SYSTEM SERVICES
EXIT/EMERGENCY LIGHTING SYSTEMS: Would you like your business set up on an ANNUAL basis? (Per NFPA 101 and Local Fire Codes) Special circumstances? Use OTHER and explain.
*
Yes - Enter the next required service date below.
Not interested in this service
Other - Special Circumstances
If you answered OTHER, please explain the special circumstances.
If you answered YES or OTHER, enter the date when your next service is required. Skip if you answered NOT INTERESTED.
-
Month
-
Day
Year
Date
Back
Next
FIRE DOOR SERVICES
FIRE DOORS: Would you like your business set up on an ANNUAL basis? (Per NFPA 80 and Local Fire Codes) Special circumstances? Use OTHER and explain.
*
Yes - Enter the next required service date below.
Not interested in this service
Other - Special Circumstances
If you answered OTHER, please explain the special circumstances.
If you answered YES or OTHER, enter the date when your next service is required. Skip if you answered NOT INTERESTED.
-
Month
-
Day
Year
Date
Back
Next
CONCLUSION
To complete this form, please read and check the acknowledgment boxes, and the signature section.
CANCELATION POLICY: I understand that advanced notification of at least 30-days is required to cancel future services.
*
Yes, I understand this SERVICE CANCELATION policy.
BILLING POLICY: I understand that Jefferson Fire & Safety, Inc.’s terms are NET 20 days from invoice date and that finance charges of 1-1½% per month will be assessed on past due balances. In the event the account is referred for collection, this company agrees to pay all costs of collection, including court cost and reasonable attorney fees.
*
Yes, I understand this BILLING policy.
YOUR NAME
*
First Name
Last Name
YOUR TITLE
*
Signature
Submit
Should be Empty: