MPS Monitor Refusal Form

MPS Monitor Refusal Form

MPS Monitor is POA’s automatic meter reading software. It allows us to have your meter counts sent to us directly from your machine(s), saving you the time and trouble of reporting them to us manually, as well as enabling optional auto toner replenishment.
Please make sure this customer isn't already reporting in MPS
Account Details
Date

MonthDayYear
Date
Branch #
Company name
Name MUST match name in OMD
Customer ID
Equipment ID's 1 per line
Contact Name

First NameLast Name
Phone Number
Format: 0000000000.
Contact E-mail
Tech Name

First NameLast Name
Sales Rep Name

First NameLast Name
Reason for Refusing MPS Monitoring
Why doesn't the customer want MPS Monitoring?
Contact for Manual Reads
Authorized Person’s Contact
Want More Information
IT Contact
Contact

First NameLast Name
Which contact information do you have? (One is required but both is great)
Email
example@example.com
Phone Number
10 digits no formattingFormat: 0000000000.
Have a Second Contact?
Second Contact

First NameLast Name
Second Contact Email
example@example.com
Second Contact Phone Number
Format: 0000000000.
Notes
Customer Signature
Date Signed

MonthDayYear
Date
*By refusing, customer agrees to provide POA with timely meter counts and could cause a delay in billing or estimation.
Should be Empty: