ULTRA PURE

PURIFIED BOTTLED WATER SERVICE AGREEMENT

716 S. Grape St. Medford, OR 97501 541-734-0828

DATE	ROUTE	STOP #	ACCOUNT#

The above for office use only

EMAIL Billing Address will be email unless specified otherwise	PHONE	TEXT OK yes/no

NAME	If a business contact name and phone

DELIVERY ADDRESS	CITY	ZIP CODE

Please read and initial the boxes below

I understand that the card I put on file will be charged monthly for the previous month’s water service and that any disruption in payment will lead to disruption of service and possible termination of account.

I understand that if I dispute a charge I must notify Ultra Pure Water within 15 days of invoice or debt will be considered valid and non-refundable.

I understand that Ultra Pure bottles and water dispensers are not to be filled with any substance other than Ultra Pure Water and that lost or damaged bottles will be charged $12.00 (5g) or $10.50 (3g) per bottle.

I understand that Ultra Pure Water is not responsible for water damages or spillages of any kind.

I understand that any unused water is non-refundable.

Minimum Water Service $	Price Per Bottle $7.00

Dispenser Monthly Rental $	dispenser lease agreement is a separate contract

Total minimum cost per month $ NOTES

I agree to pay a minimum of $per month, which includes up to bottles of water. Additional bottles will be charged at the agreed upon price per bottle above. I understand that this charge is not a deposit and is non-refundable. I understand that the bottles are not to be refilled with any other liquid or foreign material. I agree to pay for loss of or damage to this equipment. Said equipment shall under no circumstances be considered fixtures on the premises and shall be removable personal property of Ultra Pure Water. I give Ultra Pure Water permission to enter premises where equipment is housed to retrieve equipment should default of contract occur. I understand that personal removal of equipment is not permitted without prior authorization from Ultra Pure Water. Failure to pay according to these terms will result in suspension and /or termination of services. Ultra Pure Water Inc. has the right to refuse, or terminate services with any person, organization or company.

Bottles for 1st delivery 5gal 3gal Bottle(s) free on setup

CUST. SIGNATURE

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