Service Agreement Application

*Business Name:

*Business Name (DBA):

*Business Phone:

*Business Address:

*City:

*State:

*Zip:

*Years in business:

*Number of other locations:

*Legal Type:

Sole Proprietorship
Partnership
Corporation
LLC

*Package:

Silver ($99.99/month)
Gold ($119.99/month)
Platinum ($129.99/month)

Monitors:
(optional)

15 inch Flat screen (add $7.99/mo)
17 inch Flat screen (add $9.99/mo)

*Insurance:
(optional)

Yes
No

*Check Guarantee:
(optional)

Yes
No

Principal / Owner Information

*Full Name:

*Title:

*Address:

*City:

*State:

*Zip:

*Phone:

*Email:

*Date of Birth:

(mm/dd/yyyy)

Questions/Comments:

* You acknowledge that by signing this service agreement application, you agree to the terms and conditions of General Technology Company.

* required fields