- SEPS Inc.

Service Site Info

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Contact Name*

First Last

Title*

Phone*

Email*

Billing Address: If different from site address

Company Name

Address

Street Address Address Line 2 City State ZIP Code

Payment Info

Tax Exemption Status

Non-Exempt
Exempt

Tax Exemption Form

PO# (If Using A PO)

Upload PO If Needed

***If you wish to provide a credit card please complete this form and then contact our customer care department at 630-986-8899 to complete the request.

Actual invoices charges shall be contingent upon actual services rendered and material provided.

Service Request Information

Manufacturer*

Model Number*

Serial Number*

Tech to evaluate unit. Not guaranteed to fix on first visit, return visit may be needed. Minimum of four hours billing for services based on these rates.

Additional Comments

Upload Additional Photos and Documents

We are pleased to submit the Service Authorization Form to perform services on your equipment per standard Terms and Conditions. It is understood if acceptance of this proposal is acknowledged on the customer’s purchase order, such acceptance will be subject to the Terms & Conditions of this Service Authorization From with the same force and effect as though they were included on the customer’s purchase order.

*
I have read and understood the rates.*

*
I have read and agree to the terms and conditions.*

Consent*
By checking this box and typing my name below, I am electronically signing this application.*

Name*
First Last

TIME & MATERIAL AUTHORIZATION FORM

Service Site Info

Billing Address: If different from site address

Payment Info

***If you wish to provide a credit card please complete this form and then contact our customer care department at 630-986-8899 to complete the request.

Service Request Information

Contact

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