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The Illuminating Company <br />CUSTOMER WORK APPROVAL AND PAYMENT DESIGNATION <br />FORM 1039 (REV. 10-05) <br />in Nn Sn1 Innl t <br />.: <br /> <br />a <br />CUSTOMER'INFOR.MATION `;(Piease`Print) <br />CUSTOMER NAME / <br />e! 7'-y OF 1\1012% l7 OZ!"?% W -0 ACCOUNT NO. <br />SERVICE ADDRESS . SUITE NO. DAY PHONE N0. <br />zib 31f9 - 79 <br />CITY <br />r? ZIP CODE <br />a7 v EVENING PHONE N0. <br />MAILING ADDRESS <br />CITY STATE ZIP CODE <br />I request to have The Illuminating Company perform the work described below at the above address. I agree that final scheduling of <br />this work will not begin until payment of the agreed price below is received by The Illuminating Company. I understand that quoted <br />prices remain in effect for only 30 days. In Jobbing and Contracting related work I understand that other providers are available to <br />perform this work. The services I currently receive from the Illuminating Company will not be impacted in any way regardless of the <br />provider I select to do this work. This is not an invoice. <br />CUSTOMER NAME (Or DBA / Inc.) CUSTOMER SIGNATURE <br />IF COMMERCIAL OR INDUSTRIAL CUSTOMER - SIGNEE'S TITLE IN THE COMPANY DATE <br />If there are any questions concerning this work please call The Illuminating Company at 1-800-589-3101. <br />aE k. <br />? ,:.?- ?--?? .k <br />? <br />??,,,?? <br />.: . <br /> <br /> <br />,a. ,?. <br /> <br /> <br />?. .. ..,. .?,, . . <br /> <br /> <br />?? ? .. ? <br />WORK <br />TYPE CREWS WORK <br />REQUEST NO. <br />SAP ORDER NO. <br />WORK DESCRIPTION <br />PRICE <br /> <br /> <br /> <br /> <br /> <br />WORK TYPES: SIC - SERVICE INSTALLATION CHARGES SUB TOTAL S 3I? <br />J&C - JOBBING AND CONTRACTING - INCLUDE LIABILITY FORM <br />ATC - AID TO CONSTRUCTION <br />IF APPLICABLE, TAX <br /> OR TAX EXEMPT N0. <br />IF WORK INCLUDES JOBBING AND CONTRACTING, APPLICABLE SALES AND USE TAXES <br />ARE INCLUDED IN THE TOTAL PRICE. TOTAL PRICE r•. ??' <br />ILLUMINATING COMPANY R RESENTAT?E (Print) <br />? , GC? ? h0 ?'` ILLU NATING COMPANY REP?ENTATij ('gnature <br />? !? <br />PAYMENT AMOUNT <br />CREDIT CARD PAYMENTS WILL BE CHARGED A PROCESSING FEE BASED ON THE COST OF THE JOB. <br /> ? MASTERCARD ? VISA ? DiSCOVER <br />NAME AS IT APPEARS ON THE CREDIT CARD (Please Print) ACCOUNT NO. EXPIRATION DATE THREE DIGIT PIN (From The Back OFThe Cred'n Card) <br />BILLING ADDRESS FOR CREDIT CARD ACCOUNT CITY STATE ZIP CODE <br />THE CUSTOMER WILL INCUR A$20 CHARGE FOR ANY CHECKS RETURNED FOR NON-SUFFICIENT FUNDS. <br />RETURN THE SIGNED FORM IN THE ENVELOPE PROVIDED OR MAIL TO THE ADDRESS BELOW. <br />BUSINESS SERVICES - NRHQ-112 <br />THE ILLUMINATING COMPANY FAX - CREDIT CARD FORMS MAY BE FAXED TO 440-546-8849 <br />76 SOUTH MAIN STREET <br />AKRON, OH 44308-1890 <br />COPY DISTRIBUTION: 1- THE ILLUMINATING COMPANY, 2- CUSTOMER - INCLUDE WITH PAYMENT COPY, 3- CUSTOMER COPY