Service Call or Time and Material Request

To request service, please fill out and submit the following information.
We'll respond to your request as soon as possible.

(Fields in Red are required)

Responsible Party for This Request
(requestor is responsible for payment)

Requestor:
Company:
Address:
City:
Email Address:
State: Zip: -

Work to be performed:
Use this space to tell us about the work needed.

Information on location where work is to be performed:

Job Name (and number):
Location:
Address:
City:
State: Zip: -

Owner:
General Contractor:
Job Contact:
Phone:( ) - Ext:
Phone (Alt):( ) - Ext:

Email Address:

Purchase order #:

Special Billing Instructions:

Use this space to tell us about special billing instructions (i.e. work not to exceed a specified amount, verbal negotiated price, etc.)

Our rates are $73.00 per man hour with a minimum of 1 hour
during regular business hours (M-F from 7:30am-4:30pm)

I understand the work herein authorized is not part
of any other contract or job or work order.
Requestor Initials:
Requestor is responsible for payment.