Irrigation System Maintenance Agreement


Service Address:

Service City:

New Customers: Please provide service address
if different from billing.

Billing Information:
* Required


*First Name:


*Last Name:


*Billing Address:






*Zip Code:


*Mobile Number (for appt. reminders):


*Email (for appt. reminders):


Mobile Number:




(skip this section if it does not apply to you) 

First Name:


Last Name:


  By checking this box, I authorize the above caretaker to schedule service appointments for my irrigation system. I understand that I will be billed directly for all repairs and services.


Agreement and Authorization

By submitting this form, I authorize Gilford Well Company, Inc. to perform the following services (select the services you want each year):


Service Description

Preferred Time of Year

Standard Rate

Prepaid Rate


  • Installation of pump (if required), suction hose or backflow preventer
  • Check of each zone for damaged parts (parts are billed separately)
  • Timer set for spring watering (may need to be adjusted when hot, dry weather arrives)

Early Spring
Mid Spring
Late Spring


(if paid by April 15)


  • Blow out lines with air compressor
  • Remove pump/backflow (store at location or GWC)
  • Note any repairs to be made in spring

Early Fall
Mid Fall
Late Fall

(pay when invoiced)

Does not apply

Please remove me from the list, I no longer require these services



Credit Card (Optional Pre-Payment):



Credit Card Number:


Expiration Date:


Amount to Charge:



what is this?The Credit Card Verification Value is the 3 digit code on the back of your card.


I Authorize Gilford Well Company to charge
the above credit card for the amount given:


Please type this verification code below:




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