New Customer Information / Payment Authorization Form

New Customer Information/Payment Authorization Form

We Look Forward to Serving You!

The most successful relationships are built on TRUST. We are proud to say that many of our customers have been with us for over a decade because of the trust we’ve built by consistently delivering on our promises and sharing open communication…. and of course, the GREAT service too! We want our partnership to be no different with YOU!!

Some housekeeping before we get started…

In order to secure your service call, you’ll need to complete and send the form below.
Our service rates are as follows: Flat rate of $330.00 which includes travel and 1 hour of labor. Labor: $165.00 per hour billed in 1/2 hour increments thereafter. Parts and materials are additional as needed. These rates apply to work hours between 6:00am and 6:00pm, Monday through Friday.
Overtime rates will apply to all work performed between 6:00pm and 10:00pm, Monday through Friday and Saturday from 6:00am to 6:00pm. Overtime rates are as follows: Flat rate Call Out O/T service charge of $496.00 which includes travel and 1 hour of labor. Labor: $248.00 per hour billed in 1/2 hour increments thereafter. Parts and materials are additional as needed.
Double time rates apply to all work performed after 10:00pm Monday through Friday, after 6:00pm on Saturday, all day Sunday, and on any non-working holidays. Double time rates are as follows: Flat rate Call Out D/T service charge of $660.00 which includes travel and 1 hour of labor. Labor: $330.00 per hour billed in 1/2 hour increments thereafter. Parts and materials are additional as needed.
Equipment Install/Removal Site Survey – Flat rate of $330.00.
You may pay by Credit Card (on file), Cash or Company Check upon the completion of your service call.

Tell us about yourself.

Today's Date

First Name

Last Name

Company Name

Company Industry

Company Website

Company Address

City

State

Zip

Phone

Mobile Phone

SMS Status Updates

Click this checkbox to receive SMS status updates concerning my account including service appointments and confirmations, service status, billing updates and customer satisfaction. Message frequency varies by service call. Message and data rates apply. Reply STOP to opt out or HELP for more information. View our terms and privacy policy.

Accounts Payable First Name

Accounts Payable Last Name

Accounts Payable Phone

Accounts Payable Email

Does A/P require a PO for Invoice Payment Processing?

YES NO

How did you hear about us?

By checking this acceptance of terms box, I agree that I have read and understand, and agree to pay for the service rendered per the terms above. If I do not have cash or a company check available, or if I am not at the service location when the work is completed, I then authorize Jay-Hill Repairs to charge the credit card I provided when booking this service call. I understand that payments may not post to my account for up to 3 business days and that if the electronic debit or credit card payment is returned unpaid, a $50.00 return item fee for each payment or the maximum allowed by law will be added to my account and will be due immediately.

Acceptance of Terms

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