Concrete Scheduling Form CP

Concrete Appointment*
Account Information

Please fill out the following questions as it helps us create your account and ensure proper information can be provided on receipts.
Company Name*
If you are a homeowner, please fill in your personal information.
Company Phone Number
Please enter a valid phone number.
Company Address/Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Accounts Payable Name

First NameLast Name
Accounts Payable Email
example@example.com
PO/Job Number
Project Name*
On-site Contact Name*

First NameLast Name
On-site Phone Number*
Please enter a valid phone number.
On-site Email Address*
example@example.com
Project Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yards Requested *
*NOTE: Any orders under 3 yards will be charged at a 3 yard minimum. After hours and weekends are subject to change based on workload.
Mix Design *
Project Type
Unloading Method*
Payment Method*
*NOTE: A 3.5% fee will be charged for credit card transactions.
AR Mobile Concrete provided Equipment
Truck Washout Option*

Washout on-site $0.00Washout in ARMC provided bag (left on-site) $50.00No Washout $200.00
Additional water added to this concrete will reduce its strength. Any water added is at the customer's own risk.

Concrete pours are allotted 1 (one) hour per truck. Time on-site past 1 (one) hour will be charged at a rate of three dollars ($3.00) per minute.

Credit Card Hold Agreement
Client acknowledges and agrees that a valid credit card is required to secure the scheduled concrete pour date, regardless of the final method of payment. This hold is for scheduling purposes only and will be released within twenty-four (24) to forty-eight (48) hours after the completion of the scheduled pour. By signing this Agreement, the Client accepts these terms and authorizes the Contractor to place a temporary hold on the provided credit card accordingly.
Terms and Conditions of Sale:

In consideration of AR Mobile Concrete delivering the described material to a place designated by the Customer, the Customer hereby releases and agrees to indemnify and hold harmless AR Mobile Concrete and its employees from all liability or claims for damage done by them, resulting from the movement of AR Mobile Concrete vehicles upon or about the delivery location.

Customer acknowledges that the material described has been selected solely by the customer without AR Mobile Concrete having reviewed any plans or specifications relating to the project on which the material is to be used. Customers agree to defend, indemnify and hold harmless from all liability for claims for damage related to said material being inappropriate, improper or inconsistent with plans and specifications, or with the ground soil or conditions on the land where the material is fully permitted by law. If AR Mobile Concrete retains the services of an attorney to collect payment for the described materials, the customer agrees to pay reasonable attorney fees incurred by the Company. Customer agrees to pay a time price differential of 1.5% per month on any amounts owed to AR Mobile Concrete for more than thirty (30) days.
Signature*

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First NameLast Name
How did you hear about us?*

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Account Information