BA/SPA/Usage/Use-Risk Request

IF WQI IS INCLUDED IN YOUR BA REQUEST, USE THE DIGITALLY ENABLED SERVICE PROGRAM AGREEMENT REQUEST FORM (CLICK HERE) TO REQUEST A DIGITAL PROGRAM AGREEMENT OR PROPOSAL AND BILLING ARRANGEMENT SETUP

IMPORTANT

WHEN ORDERING 3DTRASAR EQUIPMENT:

New Construction Business

Institutional - DO UTILIZE THIS FORM AND PLACE UNDER ‘GENERAL EQUIPMENT’
FBMN/TR/TS – DO NOT UTILIZE THIS FORM – USE EZ SETUP FORM

All Other Business That Requires EZ Setup

DO NOT USE THIS FORM, UTILIZE EZ SETUP FORM

Your Name: *

Your Email: *

District: *

Customer Information

Sold-To Number: *

Account Name: *

Multiple Ship-To?:

Yes

Ship-To Number:

Multiple Bill-To?:

Yes

Bill-To Number:

Request Pertains To (select one): If you are submitting a PO Change or Billing Adjustment, click the BA option. *

Using Light Pricer Tool?: *

Yes

No

Pricer Tool Upload: *

Does Pricer Tool Indicate Additional Approvals Required?: *

Yes

No

Please attach screenshot of required approvals: *

Save the document in the ‘Outlook Message Format – Unicode’ format (PDF or screenshots are not accepted).

IMPORTANT:

***Request will not be processed if approval is required***

BA Action Required: *

SPA Action Required: *

Usage Action Required: *

Use-Risk Action Required: *

Is this request to resolve a dispute?

Yes

Select Dispute Reason: *

Are CCRs (Credit & Credit/Rebill) Required?

Yes

If checked, include Approvals and CCR Template.

SBU: *

PO Status?:

Required

PO Number: *

PO Attachment:

Please note - the PO must be sufficient enough to cover the BA(s) that have been set up.

Amendment Details

BA Amendment Includes: *

Billing Arrangement Number: *

Effective Date of Change:
* +

Billing Frequency: *

Monthly

Quarterly

Yearly

Revised End Date:
(must be last day of any month) * +

Billing Arrangement Number: *

Additional Attachment (1):

Additional Attachment (2):

Additional Attachment (3):

Additional Attachment (4):

Additional Attachment (5):

Additional Attachment (6):

Price Increase/Add Product/Decrease Amount/Remove Product (per invoice): *

Add Another?:

Yes

Price Increase/Add Product/Decrease Amount/Remove Product (per invoice): *

Add Another?:

Yes

Price Increase/Add Product/Decrease Amount/Remove Product (per invoice): *

Add Another?:

Yes

Price Increase/Add Product/Decrease Amount/Remove Product (per invoice): *

Add Another?:

Yes

Price Increase/Add Product/Decrease Amount/Remove Product (per invoice): *

New Invoice Amount: *

BA Supplemental Billing

Billing Date: * +

Billing Arrangement Number: *

Reason for Supplemental Billing: *

Please choose all that apply for this Supplemental Invoice: *

Gen Service - Cooling Tower Water Management Plan (Protocol):

Gen Service - Water Management Plan:

Gen Service - Tower Cleaning:

Gen Service - Online Disinfection:

Gen Service - Other (please add description below):

Gen Service Description: 🛈

Gen Analytical - Legionella Testing:

Gen Analytical Other (please add description below): 🛈

Gen Analytical Description: 🛈

Gen Digital Amount 1: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 2: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 3: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 4: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 5: *

Programs To Be Added: *

Gen Chemical: *

Capital Equipment:

Gen Equipment: * 🛈

Set-up Details

Billing Arrangement Type: *

Fixed

One-Time Only

Billing Arrangement Type: *

Usage

Billing Arrangement Type: *

Usage

Billing Arrangement Type: *

Use-Risk

Is Water Safety Included? *

Yes

No

Start Date (must be first day of any month): * +

End Date (must be last day of any month): * +

How often will the BA invoice?: *

Will this renew?: *

Yes

No

How much should each invoice amount be?: *

What is the total amount of the Billing Arrangement: *

Additional Attachment (1):

Additional Attachment (2):

Additional Attachment (3):

Additional Attachment (4):

Additional Attachment (5):

Additional Attachment (6):

1. Price Per Unit: *

Annual Unit Forecast: *

Add Another?:

Yes

2. Price Per Unit: *

Annual Unit Forecast: *

Add Another?:

Yes

3. Price Per Unit: *

Annual Unit Forecast: *

Add Another?:

Yes

4. Price Per Unit: *

Annual Unit Forecast: *

Water Safety Details

Please select all that apply: *

AquaPath Sensing *

Legionella Testing: *

Domestic Water C&D: *

POU Filters: *

Supplemental Disinfection: *

Water Management Program (WMP): *

Please provide amount or product to decrease (if applicable)

Please choose all that apply for this BA: *

Capital Equipment - Annual Amount

Capital Equipment Annual Lease Fee: *

Capital Equipment - Part #1: * 🛈

Add another part?:

Yes

Capital Equipment - Part #2: * 🛈

Add another part?:

Yes

Capital Equipment - Part #3: * 🛈

Add another part?:

Yes

Capital Equipment - Part #4: * 🛈

Add another part?:

Yes

Capital Equipment - Part #5: * 🛈

Add another part?:

Yes

Capital Equipment - Part #6: * 🛈

Add another part?:

Yes

Capital Equipment - Part #7: * 🛈

Add another part?:

Yes

Capital Equipment - Part #8: * 🛈

Add another part?:

Yes

Capital Equipment - Part #9: * 🛈

Add another part?:

Yes

Capital Equipment - Part #10: * 🛈

IF ADDITIONAL PART NUMBERS ARE NEEDED, PLEASE ENTER EACH OF THEM IN THE SPECIAL INSTRUCTIONS SECTION AT THE BOTTOM OF THE FORM.

Is this part of a technology or equipment fund?: * 🛈

Yes

No

Gen Equipment - Annual Amount

Gen Equipment - Other: * 🛈

General Equipment Part # (required if part is >$1,000)

Gen Equipment - Part #1: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #2: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #3: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #4: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #5: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #6: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #7: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #8: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #9: *

Quantity (each): *

Add another part?:

Yes

Gen Equipment - Part #10: *

Quantity (each): *

Gen Service - Annual Amount

Gen Service - Cooling Tower Water Management Plan (Protocol):

Gen Service - Water Management Plan:

Gen Service - Tower Cleaning:

Gen Service - Online Disinfection:

Gen Service - Other (please add description below):

Is Gen Service Line Taxable? *

Yes

No

Please provide Ship-To# 🛈

Gen Service Description: 🛈

Gen Analytical - Annual Amount

Gen Analytical - Legionella Testing:

Gen Analytical - Other (please add description below): 🛈

Gen Analytical Description: 🛈

Gen Digital - Annual Amount

Gen Digital Amount 1: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 2: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 3: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 4: *

Programs To Be Added: *

Add Another Digital Offering?:

Yes

Gen Digital Amount 5: *

Programs To Be Added: *

Chemical - Annual Amount

Gen Chemical (Annual Increase/Decrease Amount): *

1. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

2. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

3. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

4. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

5. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

6. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

7. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

8. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/lb): *

Price/Pound ($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

9. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound($/lb): *

Price/Kilogram($/kg): *

Price/Kilogram ($/kg): *

Add another product?:

Yes

10. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Kilogram ($/kg): *

IF ADDITIONAL PRODUCTS ARE NEEDED, PLEASE ENTER EACH OF THEM IN THE SPECIAL INSTRUCTIONS SECTION AT THE BOTTOM OF THE FORM.

Is discount pricing above 10% being applied? *

Yes

No

Please attach screenshots of the completed Pricer Tool and the required approvals (attach as a single word document): *

Usage Billing

Use-Risk Billing

IMPORTANT:

INFORMATION MUST BE RECEIVED PRIOR TO 3:00 PM CST ON THE

LAST BUSINESS DAY OF THE MONTH TO POST FOR CURRENT MONTH
LATE ENTRIES CANNOT BE BACKDATED.

Billing Date: * +

Billing Arrangement Number: *

PO Number:

PO Attachment:

Upload Billing Spreadsheet: *

Yes

No

Billing File Upload (1): *

Billing File Upload (2):

Item Detail

Item #1: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #2: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #3: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #4: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #5: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #6: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #7: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #8: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #9: *

Quantity: *

Unit Price: *

Add another item?:

Yes

Item #10: *

Quantity: *

Unit Price: *

IF ADDITIONAL PRODUCTS ARE NEEDED, PLEASE ENTER EACH OF THEM IN THE SPECIAL INSTRUCTIONS SECTION AT THE BOTTOM OF THE FORM.

SPA Details

SPA Type: *

On-going SPA

One-time SPA

One-Time No Charge Quote

SPA Amendment Action: *

SPA Number: *

Effective Date of Change: * +

Revised End Date (must be last day of any month): * +

Add More Than 10 Products to SPA or ADPAS Proposal? *

Yes

No

Product List (ONLY IF MORE THAN 10 PRODUCTS or ADPAS Proposal) *

1. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

2. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

3. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

4. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

5. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

6. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

7. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

8. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

9. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Add Another Product?:

Yes

10. Product # . Package Code: *

Quantity (each per year): *

Please Select: *

Price Per Pound

Price Per Kilogram

Price Per Each

Price Per Gallon

Price/Pound ($/lb): *

Price/Kilogram ($/kg): *

Price/Each ($/ea): *

Price/Gallon ($/gal): *

Notes for CF Approval: (provide details - who approved pricing, etc.) *

Invoice Text (if none, indicate N/A): * 🛈

Special Instructions/Comments: *

Purchase Order Change

1. Order #:

Invoice #:

Old Purchase Order#: *

New Purchase Order #: *

Notes: *

Upload #1:

Upload #2:

Billing Adjustment

Approval:

Attachment:

Notes: *

Item #1: Product.pkg *

Order Number:

Invoice Number:

Current Price: *

Quantity: *

Current Unit of Measure: *

Each

Pound

Gallon

Kilogram

New Price: *

Quantity: *

New Unit of Measure: *

Each

Pound

Gallon

Kilogram

Add another item?:

Yes

Item #2: Product.pkg *

Order Number:

Invoice Number:

Current Price: *

Quantity: *

Current Unit of Measure: *

Each

Pound

Gallon

Kilogram

New Price: *

Quantity:

New Unit of Measure: *

Each

Pound

Gallon

Kilogram

Add another item?:

Yes

Item #3: Product.pkg *

Order Number:

Invoice Number:

Current Price: *

Quantity: *

Current Unit of Measure: *

Each

Pound

Gallon

Kilogram

New Price: *

Quantity: *

New Unit of Measure: *

Each

Pound

Gallon

Kilogram

Add another item?:

Yes

Item #4: Product.pkg *

Order Number:

Invoice Number:

Current Price: *

Quantity: *

Current Unit of Measure: *

Each

Pound

Gallon

Kilogram

New Price: *

Quantity: *

New Unit of Measure: *

Each

Pound

Gallon

Kilogram

Add another item?:

Yes

Item #5: Product.pkg *

Order Number:

Invoice Number:

Current Price: *

Quantity: *

Current Unit of Measure: *

Each

Pound

Gallon

Kilogram

New Price: *

Quantity: *

New Unit of Measure: *

Each

Pound

Gallon

Kilogram

Please Note - DM approval required for all billing adjustments (AVP if no DM is present in the district).

Save the document in the ‘Outlook Message Format – Unicode’ format (PDF or screenshots are not accepted).