Lou Negley's Bottled Water Service

Lou Negley's Bottled Water, Inc.

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106 Corks Ln, Butler, PA 16001

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Lou Negley Residential Form

Lou Negley Residential Form

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Residential Account Setup Form

Date

Salesperson

Account #

New Field:

NEW ACCOUNT

UPDATE

RENAME

ADD SHIP TO

ADD SHIP TO

Free Text

Credit Information

Name

Contact

Home#

Cell#

Office#

E-mail

Billing Address

Free Text

Billing Information

New Field:

OPEN ACCOUNT

CREDIT CARD

ONE TIME ONLY

CONTINUAL CHARGE

New Field:

ASSIGN PRICE LIST #

New Field:

New Field:

INVOICE BY E-MAIL

E-mail

How did you hear of us

Ship to #1

WATER

COFFEE

Name

Contact

Street

Phone

Department

Cell

Floor/Room #

E-mail

City

State/Zip

Free Text

Routing / Delivery Instructions

Routing / Delivery Instructions

MONTHLY

BI-MONTHLY

WILL CALL

RENTAL ONLY

Free Text

Special Instructions

Special Instructions

Free Text

Product Type

Free Text

Quantity

Free Text

Price

Free Text

Price Protected Term Date

Free Text

Amount

New Field:

New Field:

New Field:

New Field:

New Field:

New Field:

New Field:

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New Field:

New Field:

New Field:

TOTAL BEFORE TAX

Date

Reviewed By

New Field:

Approved

Denied

CUSTOMER SIGNATURE

DATE

Thank you for contacting us.
We will get back to you as soon as possible.

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CONTACT INFORMATION

Address: 106 Corks Ln, Butler, PA 16001
Phone: 724-282-6160

Mon-Fri	08:30 AM - 04:30 PM
Sat-Sun	Closed

OUR LOCATION

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Home
Water & Coolers
Water Treatment & Filtration
Salts
Contact
Forms

CONTACT INFORMATION

Address: 106 Corks Ln, Butler, PA 16001

Phone: 724-282-6160

Mon-Fri	08:30 AM - 04:00 PM
Sat-Sun	Closed

OUR LOCATION

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