* BY COMPLETING THIS FORM CUSTOMER AGREES WITH THE RATES AND TERMS LISTED ABOVE, AKNOWLEDGES THAT HE OR SHE HAS AUTHORITY TO REQUEST SERVICE ON BEHALF OF HIS OR HER LOCATION AND THAT ALL INFORMATION LISTED ABOVE IS CORRECT.
* BY COMPLETING THIS FORM CUSTOMER AGREES WITH THE RATES AND TERMS LISTED ABOVE, AKNOWLEDGES THAT HE OR SHE HAS AUTHORITY TO REQUEST SERVICE ON BEHALF OF HIS OR HER LOCATION AND THAT ALL INFORMATION LISTED ABOVE IS CORRECT.