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TECH
Pests & Termites
St. Lucie: 772-429-7716 · Martin: 772-287-8486 · Indian River: 772-567-7392 . Jupiter: 561-746-7364
5203 Okeechobee Road
Fort Pierce, Florida 34947
DATE TAKEN: \ - '3 f--ot
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MAILING ADDRESS
P.O. Box 1766
Fort Pierce, FL 34954-1766
FOR FAST, PROFESSIONAL SERVICE CALL
CUSTOMER INFORMATION
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HOME TEL #
Acct. #
SERVICE REQUESTED
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STATE ZIP CODE/GRID
WORK TEL #
CONTRACTS:
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PAYMENT / CREDIT CARD INFORMATION
AMT CARD TYPE CHECK # / CARD # / EXP "DATE
AMT
AUTHORIZATION
CODE DATE
TIME
1 .
2.
3.
4.
TOTAL DUE TOTAL AUTH. DEFERRED DATE
CARDHOLDER NAME (If different from above)
I AGRJ;:E TO PAY ABOVE TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT (Visa/MasterCard Customer Inquiries Call 1-800-920-1079).
SIGNATURE:
DATE:
VALUED CUSTOMER COMMENTS:
SALES TECH COMMENTS:
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PEST CONTROL / FLEAS / OTS
DATE
TERMITE / FUME
INSPECTED Evidence Treated
SITES (Y/N) (Y/N)
Foundation
Crawl Space
I nterior Walls
Door Frames
Window Frames
Bath Traps __
AttiC) J , .
Other t/' )(tiH~ "",--k'A',
/ ..i.ATERIAL
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TREATMENT SITES
TREATED
MATERIAL
Name (%) & Amt
Mulch/Flowerbeds
Woodpile/Garbage Area
Doors/Wi ndows/Eaves
Attic/Crawl Space
Underneath Appliances
Wall Voids/False Bottoms
Cracks/Crevices
Drawers/Cabinets/Closets
Other
TARGET PESTS
Endorsement hereon acknowledges receipt of and satisfaction for services rendered.
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CUSTOMERS SIGNATURE
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