Billing Agreement

Company Name *

Name *

First

Last

Phone *

Email *

Fax

EIN/SS#

Billing Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

How many properties do you manage?

Who else is authorized to sign under this account? Please list Below. *

Account and Billing Terms:

You will be issued an account number. Please use this number when placing orders to ensure accurate billing. Payment is due before the 15th of the following month for all invoices received by the end of the previous month. A $25 fee will be added to late payments.

• I understand and agree to the above terms and conditions, and am authorized to order work and sign on behalf of the above company and/or person.

Would you like to place a credit card on file for future payment?

• Yes
• No

Signature

Clear Signature

For further clarification regarding questions or inquiries you may have, please reach out to us via phone at: 512-648-6464 or via email at: accounts_3@rekey.com

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