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:

 

*City:

 

*State:

 

*Zip Code:

 

*Mobile Number (for appointment reminders):

 

*Email (for appointment reminders):

 

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

 
*First Name:                                               Mobile Number:
       

 
*Last Name:                                               Email:
       

 

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, you authorize Gilford Well Company, Inc. to winterize your irrigation system according to the selections you make on the form below:

 

Service Description

Preferred Time of Year

Standard Rate

Winterization

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

Every Year
2017 Season Only

$110/hour
(billed when complete)

Store pump/backflow at my location

  • GWC is not responsible for pumps stored at your location. Please be sure your pump is secured in a safe place that is protected from the elements.

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:

 

CVC#:

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:
    YES

 


Please type this verification code below:

 

         

 

 
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