HomeMy WebLinkAboutCONTROLLER sir
,/ DISTRIBUTOR:
a� Off ire H20 Office H2O pure water partners9850 North Michigan RoadSuite E
Carmel,IN 46032
www.officeh2o.com (866)621-6910
CUSTOMER INFORMATION BILLING INFORMATION (if different)
Coany Full Legal Name: Company Name:
, 4 I_NS‘Villo
Contact: J Phone #: Contact:
Phone #:
Equipmen Location Address / Address:
bb qua Lte a.�e 1 436o
City, State, ZO City, State, Zip
2-3.gLSI DA.-4 Lai \-P h k 7) So
Email: TIN#:
Email: P.O.#:
Org Type: ❑ Corp ❑ LLC ❑ Partnership ❑Other
State incorporated/organized:
RENTAL TERM MONTHLY PAYMENT BILLING FREQ./TYPE SPECIAL INSTRUCTIONS
Quarterly payments save you
time and money!
60 months $ 9 9 . o u Z Quarterly ❑Check
(plus taxes) ❑Monthly ❑ ACH
EQUIPMENT SCHEDULE ACCOUNT SETUP FEES
Installation Fee
$ / Unit = $
Other Fees* = $
❑ See attached equipment schedule (if applicable).
*
ACH INSTRUCTIONS
By providing the bank account information herein, I (we), as the account holder(s), authorize the Distributor or its assignee and our
or its financial institution to debit our account for the amounts due or to become due under the terms of this Rental Agreement. This
authorization will remain in effect until written notification of termination is received by the Distributor or its assignee.
Routing #: Account#:
Account Name: Authorized Signer:
Agreed and Accepted
Customer:
717,,eF/7?oo2e
Authoriz d Signature 4
Name Printed
/72a /c ? g//8
Distribut We
Date
4i, c d— <8Ierxo - . 'L 2 - za —I
c .2
Signature Title
Date
Customer acknowledges h ing read and understood all of the terms of this Rental Agreement, including page 2
hereof, and agrees to be bound by all of the terms herein upon execution of this Rental Agreement.
Reference Number (for internal use only)
page 1 of 2
Ptcrir■ Customer
io Office H
Sastisfaction
Guarantee
Provided customer uses the equipment to manufacturer's
specifications, the equipment is guaranteed to perform for
the entire term of the rental period. If repairs cannot be
made, Office H2O, will replace the equipment with another
model of equal or greater capabilities at no
additional cost to the customer.
In the event that the customer becomes aware that the .
equipment does not meet minimum performance
standards, customer agrees to notify Office H2O in
writing within ten (10) business days of first knowledge of
unsatisfactory performance, Office H2O shall have five (5)
business days to correct the specified problem. In the event
the specified problem is not corrected as provided herein,
customer shall be issued a check from Office H2O equal to
the amount of one month's rental payment per
non-performing system and for each month of
non-performance commencing with the date of first receipt
of written notification of non-performance.
Agreed By:
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yc -QC) -le
ice H2O A unt Excutive Date
Cq
Custom
cy`Q6 '/8
C tact Date
Office H2O's Statement of Assurance
Office H2O is committed to providing its customer's quality equipment,
quality service and quality drinking water. If for any reason you are not
satisfied with the performance of your equipment please contact Office H2O
directly for prompt assistance.
Service@officeh2o.corn
DISTRIBUTOR:
it
pure water
artners"
Office H204Off.ce
H2O 9850 North Michigan Road,Suite E
Carmel,IN 46032
www.officeh2o.com (866)621-6910
(1:41
Customer Name: L )-PA—P ) S1 Inl...VL/
DELIVERY AND ACCEPTANCE CERTIFICATE
Customer and Distributor certify that all Equipment described in the Rental Agreement has been
delivered and properly installed according to the Rental Agreement. Customer acknowledges that
the Equipment is in good condition and is performing satisfactorily. Customer hereby accepts the
equipment unconditionally and irrevocably in accordance with the Rental Agreement and
understands that invoicing will commence upon receipt of this Certificate showing execution by
Customer. Distributor acknowledges its obligation to provide maintenance services in accordance
with any maintena _ agreement separately entered into between Distributor and Customer.
f
Customer: i► • of -ign this •-rtificate until you have actually received, installed, inspected
and accept- a I of the Equ • ent described in the Rental Agreement.
x ---,/�Y21 kr/ C 2 , /8
8
Customer(Aut orized Signature) Name(Print) Title Date
. "�n1 , A - 4-544164c y� gCrr° ISM-„-LJ c -Q6 ,—/c
it.stributor(Autg-d Signature) Name (Print) Title man_ _� L Date
MODEL SERIAL #
i.S ?1 QiLbLL
❑ See attached equipment schedule (if applicable).
Statement of Assurance
Distributor is committed to providing you with quality equipment,quality service and quality drinking water. If for
any reason you are not satisfied with the performance of your equipment or the level of service provided, please
contact us directly for prompt assistance.
Reference Number (for internal use only)