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.

Customer Information

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Multiple Bill-To?:

Supplemental Billing

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Gen Digital

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Set-up Details

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Water Safety Included?: *
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Water Safety Details

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Amendment Details

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Billing Frequency: *
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Capital Equipment

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

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General Equipment - Annual Amount

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

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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

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Gen Analytical - Annual Amount

Chemical

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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?: *

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.
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Item Detail

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

SPA Details

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Billing Adjustment


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Usage Billing