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???.. <br />N? <br />The Illuminating Company <br />CUSTOMER WORK APPROVAL AND PAYMENT DESiGNATION <br />FORM 1039 (REV. 10-05) <br />ID NO. 56110011 <br />ol <br />'C.USTOMER:INFORMATION;;(Please Print),-: <br />CUSTOMER NAME <br />d',? ? ?F &(o?2 iH k175 % ACCOUNT NO. <br />SERVICE ADDRESS <br />7-I590 SUITE N0. pAY PHONE N0. <br />.?, 3 `7S <br />CITY <br />IL 24 iL 0L ,.-W 5 7 r? ZIP CODE <br />Liq0 7 v EVENING PHONE NO. <br />MAILING ADDRESS <br />CITY STATE ZIP CODE <br />1 request to have The Iituminating 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 catl The Illuminating Company at 1-800-589-3101. <br /> ?fR?'H?`IL?:UMIN????'lMC?QMP„AN? <br />?'U????1L???"?????`? <br /> . . _. ,.„ .,. <br />.. _ <br />. .., .._ .... ... . . . . .. .. ..<, ?._ ,.. . ? -.,a ... . ,?, , ..,. .,. . .,H <br />WORK CREWS WORK <br />TYPE REQUEST NO. SAP ORDER NO. WORK DESCRIPTION PRICE <br /> i ?,?, -? <br />?5 °? a ti <br />,3 <br />31 <br /> -- , <br />1 <br /> <br />..f G Go,v er2e-7= Ific1 i Ns ??t ?rt. `7 C) Z. &0 <br /> <br /> <br />WORK TYPES: SIC - SERVICE INSTALLATION CHARGES SUB TOTAL 3 ` 00 <br />J&C - JOBBING AND CONTRACTING - INCLUDE LIABILITY FORM <br />ATC - AID TO CONSTRUCTION IF APPLICABLE, TAX <br /> ORTAX EXEMPT NO. <br />- <br />IF WORK INCLUDES JOBBING AND CONTRACTING, APPLICABLE SALES AND USE TAXES T TOTAL PRICE I? <br />3 <br />C? ? <br />ARE INCLUDED IN THE TOTAL PRICE. lo ? <br />c <br />IL INATING COMPANY REPRESENTyTIVE (Print) ILLUMING COMPAN <br />Y REPRESEpYQ4TIVE 4 n re) <br />K <br />0 ? <br />r ? <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 COUNT N0. EXPIRATION DATE THREE DIGIT PIN (Frwn The eadc 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 />.. „? <br />? <br />COPY DISTRIBUTION: 1- THE ILLUMINATING COMPANY, 2- CUSTOMER - INCLUDE WITH PAYMENT COPY, 3- CUSTOMER COPY