Billing Request

IMPORTANT:

IF ORDERING 3DTRASAR EQUIPMENT THAT
REQUIRES AN EZ SETUP FORM, DO NOT FILL OUT THIS FORM

UTILIZE THE EZ SETUP FORM INSTEAD.

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): *

BA Action Required: *

SPA Action Required: *

Usage Action Required: *

Use-Risk Action Required: *

Supplemental Billing

Billing Date: * +

Billing Arrangement Number: *

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

PO Attachment:

Billing Arrangement Number: *

Reason for Supplemental Billing: *

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

Gen Equipment: * 🛈

Gen Digital

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 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 Chemical: *

Set-up Details

Billing Arrangement Type: *

Fixed

One Time Only

Billing Arrangement Type: *

Usage

Billing Arrangement Type: *

Use-Risk

Water Safety Included?: *

Yes

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

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

How much should each invoice amount be?: *

Price Per Unit: *

Annual Unit Forecast: *

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

PO Attachment 1:

PO Attachment 2:

Additional Attachment 1:

Additional Attachment 2:

Additional Attachment 3:

Additional Attachment 4:

Additional Attachment 5:

Additional Attachment 6:

Notes for Marketing (provide details - who approved pricing?, etc.):
For Use-Risk, provide Unit of Measure (Water Used, Steam Produced, etc.
* 🛈

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

Water Safety Details

AquaPath Sensing *

Legionella Testing: *

Domestic Water C&D: *

POU Filters: *

Supplemental Disinfection: *

Water Management Program (WMP): *

Amendment Details

Amendment Includes: *

Billing Arrangement Number: *

Effective Date of Change:
* +

Billing Frequency: *

Monthly

Quarterly

Yearly

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

GM Approval (scope change requires DM approval only): *

Additional Attachment 1:

Additional Attachment 2:

Additional Attachment 3:

Additional Attachment 4:

Additional Attachment 5:

Additional Attachment 6:

Price Increase/Decrease Amount (per unit): *

Add Another?:

Yes

Price Increase/Decrease Amount (per unit): *

Add Another?:

Yes

Price Increase/Decrease Amount (per unit): *

Add Another?:

Yes

Price Increase/Decrease Amount (per unit): *

Add Another?:

Yes

Price Increase/Decrease Amount (per unit): *

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

Please provide amount or product to decrease (if applicable)

Capital Equipment

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

Gen Digital

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: *

General 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): *

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

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

Gen Service Description: 🛈

Gen Analytical - Annual Amount

Gen Analytical - Legionella Testing:

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

Gen Analytical Description: 🛈

Chemical

1. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

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/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/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/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/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/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/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 ($/kg): *

Add another product?:

Yes

9. Product # . Package Code: *

Quantity: *

Please Select: *

Per Pound	Per Kilogram
Per Each	Per Gallon

Price/Pound ($/lb): *

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/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

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

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: *

Upload Billing Spreadsheet: *

Yes

Billing File Upload: *

Billing File Upload:

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

SPA Amendment Action: *

SPA Number: *

Effective Date of Change: * +

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

GM Approval (scope change requires DM approval only): *

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

Yes

Product List (Only if more than 10 Products to SPA 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): *

Purchase Order Change

1. Order #:

Invoice #:

Old Purchase Order#: *

New Purchase Order #: *

Notes: *

File Upload:

Billing Adjustment

BA/SPA Number: Ship and Bill = N/A *

Approval:

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

Special Instructions/Notes: