CBF Service Request

Full Name*

First NameLast Name
Subdivision
Address Needing Service*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the service address the same as the billing address?*

YesNo
Billing Address/Information
Phone Number*
E-mail*
I would like to have my invoice e-mailed to me.
We mail all invoices be default unless you select the option above to receive them by e-mail instead. Please make sure to whitelist our email address to avoid missing the invoice due to spam filters.

We invoice AFTER work has been completed.
Requesting Repair For (Check All That Apply)

IrrigationLightingBackflow Prevention IssuesBackflow TestOther
Are You An Existing Customer Of Charlotte Backflow?*

YesNo
Does someone need to be present?*

YesNo
Please Describe The Issue You Are Having*

0/150
Is this a follow up to a phone call or voicemail?*

Yes, I left a messageYes I spoke with someoneNo
How would you like to receive your invoice?*

E-mailedMailed
Please select which option will work best for you, if you are not an email type person or may forget to get the invoice off your email, please select to have it mailed. There is no charge to have invoices printed and mailed.

If you are already setup for mailed invoices you will not be changed to e-mailed unless you specifically ask.
I agree that by submitting this service that I will pay all applicable service/materials charges as invoiced and that any verbal authorizations/approvals of work are hereby binding. I also agree to pay per the terms listed on the final invoice and a 1.5% monthly interest (18% per annum) charge on overdue balances and all collection costs incurred.
Should be Empty: