subject_line

Proposal for Discounted Customer Trial

Your Name: *

Your Email: *

District: *

SBU: *

FB Segment: *

IS Segment: *

MN Segment: *

TR Segment: *

Has pricing been approved by Management/Marketing/CAF?: *

Yes

No

PLEASE CONTACT MANAGEMENT/MARKETING/CAF

BEFORE PROCEEDING FURTHER WITH THIS FORM.

FB Bev/Brew Approver Name: *

FB Dairy Approver Name: *

FB Food Approver Name: *

FB Protein Approver Name: *

FB GOBS Approver Name: *

IS Healthcare Approver Name: *

IS Education Facilities, Data Centers, New Construction Approver Name: *

IS Lodging Approver Name: *

IS Govt Commercial Buildings Approver Name: *

IS Water Safety Approver Name: *

MN Microelectronics & Pharma Approver Name: *

MN Glass, HPC, Bldg. Prod., etc. Approver Name: *

TR Aerospace, Tire Approver Name: *

TR Auto, Parts Approver Name: *

Will customer be charged for trial?: *

Yes

No

How will payment be structured?: *

Please explain further: *

Business Justification

Is the value of the trial greater than $50,000?: *

Yes

No

Total Trial Value: *

What is the time frame of the trial (months)?: *

What will determine success of the trial?: *

If successful, what is the total projected value of the application?: *

How did you determine projected value?: *

Has projected value been approved by Management/Marketing/CAF?: *

Yes

No

Is there additional opportunity available at this customer?: *

Yes

No

What actions will be taken if the trial is unsuccessful?: *

Customer Information

Sold-To Number: *

Account Name: *

PO Number: *

PO Attachment 1:

Additional Attachment 2:

Additional Attachment 3:

Multiple Ship-To?:

Yes

Ship-To Number:

Multiple Bill-To?:

Yes

Bill-To Number:

Billing Arrangement Specifics

BA Type: *

Fixed

Ship & Bill

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

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

Ship & Bill Billing Details: *

How often will the BA invoice?: *

What is the total annual amount of the Billing Arrangement?: *

How much should each invoice amount be?: *

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

Please provide (if applicable)

Please choose all that apply for this BA: *

Chemical

Gen Service

Gen Equipment

Capital Equipment

Gen Analytical

Chemicals Provided

1. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

2. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

3. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

4. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

5. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

6. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

7. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

8. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

9. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Add another product?:

Yes

10. Product # . Package Code: *

Quantity (per year): *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

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

Gen Service

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: 🛈

General Equipment

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): *

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

Capital Equipment

Capital Equipment Yearly 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 Analytical

Gen Analytical - Legionella Testing:

Gen Analytical Other (please add description below): 🛈

Gen Analytical Description: 🛈

Notes for Marketing (describe BA - who approved pricing?, etc.): * 🛈

Special Instructions: