Can I e-sign this form?

Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and state UETA laws, electronic signatures are generally valid if intent, consent, attribution, and record retention requirements are met. Confirm provider acceptance and any consumer-disclosure needs.

Who must sign the form?

The owner or authorized agent should sign to grant access and approve treatments. If a tenant requests service, obtain owner authorization where required by lease or local rules.

Are notarization or witnesses required?

Not typically for routine extermination requests. Some jurisdictions or specific permits may require notarization for authorizations tied to regulatory filings; verify with local authorities.

What supporting documents are needed?

Attach photos of infestation, proof of ownership or authorization if not the owner, and any medical or allergy notes that affect permitted treatments.

How do I cancel or revoke a request?

Notify the provider in writing and retain confirmation. For electronically signed requests, follow the provider's revocation procedure and maintain records showing the cancellation.

How long should I retain completed forms?

Keep completed forms for the active contract term plus at least three years; industry or federal rules may require longer retention (see IRS and OSHA guidance).

Electronic Signature
Templates
Miscellaneous
Extermination Request Form

Extermination Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

EXTERMINATION REQUEST FORM AND SERVICE AGREEMENT

RECITALS

THIS EXTERMINATION REQUEST FORM AND SERVICE AGREEMENT (the Agreement) is entered into between:

Client Name: Contractor Name:

WHEREAS, Client requests professional pest and vermin control services for the property identified below; and

WHEREAS, Contractor is duly licensed and qualified to perform extermination services and represents that it will employ standard industry practices and applicable regulations in providing such services; and

WHEREAS, the parties intend these written terms to govern the requested service, payment, scheduling and allocation of risk.

PROPERTY & CONTACT INFORMATION

Property Address Unit/Suite (if applicable) Primary Contact

Phone:

Email:

SERVICE REQUEST DETAILS

Requested Service Date: Preferred Time Window:

Describe Infestation / Areas of Concern Type of Premises / Areas to be Treated

Residential Commercial Industrial Common Areas / Grounds

Pesticide / Treatment Preferences

Low-toxicity products preferred Non-chemical methods requested Standard chemical treatment acceptable Other:

Access / Special Instructions

SCOPE OF WORK

The Contractor shall perform extermination services as described below. The Client requests the services and acknowledges that the Contractor's obligations shall be limited to the work expressly set forth here.

Detailed Scope (treatments, frequency, target pests)

Contractor shall supply labor, materials, chemicals and equipment required to perform the Scope of Work. Any work outside this Scope shall require a separate written change order and agreement on additional compensation.

PAYMENT TERMS

Contract Price / Estimate Payment Schedule

Late Payment Fee:

Client hereby authorizes Contractor to invoice the Client in accordance with the Payment Schedule. If Client fails to pay undisputed amounts when due, Contractor may suspend services after providing the notice period specified in Term and Termination below.

TERM AND TERMINATION

Term Commencement Date: Term End Date (if any):

Either party may terminate this Agreement for material breach that remains uncured after written notice. Notice Period for termination without cause: days.

Upon termination, Client shall pay Contractor for all work performed and reimbursable expenses incurred up to the effective date of termination, subject to any offsets permitted by law.

CONFIDENTIALITY

Contractor and Client each agree to maintain as confidential all proprietary business information and technical data disclosed in connection with this Agreement, including treatment formulations, proprietary methods, pricing proposals and trade secrets (Confidential Information). Confidential Information does not include information that is or becomes publicly known through no fault of the receiving party or is required to be disclosed by law. The receiving party shall use Confidential Information only for performance under this Agreement and shall return or destroy such materials upon request.

INDEMNIFICATION AND LIMITATION OF LIABILITY

Client shall indemnify, defend and hold Contractor harmless from claims, damages or liabilities arising from Client’s failure to disclose hazards, to vacate premises as required, or from Client’s negligence. Contractor’s total liability arising out of or related to this Agreement shall not exceed the total fees paid by Client to Contractor under this Agreement for the specific service giving rise to the claim. In no event shall Contractor be liable for consequential, special, incidental or punitive damages.

HEALTH, SAFETY AND CLIENT RESPONSIBILITIES

Client is responsible for notifying Contractor of occupants with medical conditions, allergies, or special sensitivities. Client shall follow any pre-treatment and post-treatment instructions provided by Contractor to reduce exposure risk. Contractor shall post or provide written notice where required by product labels and applicable regulation.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to its conflicts of law principles. Venue for any dispute shall be in the state or federal courts located in that jurisdiction.

ENTIRE AGREEMENT

This Agreement, including any written attachments, estimates and signed change orders, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior oral or written agreements. Any amendment must be in writing and signed by both parties.

REQUEST CERTIFICATION AND AUTHORIZATION

By signing below, Client certifies that the information provided on this Extermination Request Form is accurate to the best of Client’s knowledge, that Client has authority to request treatment at the Property, and that Client authorizes Contractor to perform the Scope of Work described herein subject to the terms of this Agreement.

Known Hazards / Pets / Occupants

Client authorizes Contractor to enter the Property for the purpose of performing the agreed services: I authorize entry and treatment as described above.

FEES FOR CANCELLATION AND NO-SHOWS

Cancellation Policy: Client shall provide at least days’ notice for cancellation of scheduled services. A cancellation or no-show fee equal to may apply.

SIGNATURES

Client Printed Name:

By:

Date:

Contractor Printed Name:

By:

Date:

What the Extermination Request Form Is

The Extermination Request Form is a standardized document used to request pest-control services, record locations and consent, and authorize access for treatment. It captures requester and property details, infestation description, preferred treatment windows, chemical or non-chemical options, and signature authorization. Organizations use it to create a clear service order, document tenant or owner consent, and establish billing or warranty terms. When combined with service logs and safety sheets, the form supports regulatory compliance, customer communication, and recordkeeping for liability and follow-up treatments.

Why a Clear Extermination Request Form Matters

A well-designed Extermination Request Form reduces misunderstandings, speeds service scheduling, and documents consent and treatment scope for legal and safety purposes. Accurate forms help meet regulatory requirements and support dispute resolution by creating a dated record of the request, agreed treatment, and signer authorization.

Who Typically Completes This Form

The Extermination Request Form is completed by people responsible for pest control decisions at the property or facility.

Property owners and managers who authorize access and payments for treatment and warranty.
Tenants submitting complaints or requests that require owner or manager approval before service.
Facility or safety officers at commercial sites who coordinate access and comply with safety rules.

Different signers and audiences require different fields and supporting documents depending on ownership and industry rules.

Essential Elements of a Professional Extermination Request Form

A professional form organizes identification, location, infestation details, treatment preferences, legal authorizations, and follow-up instructions to make scheduling and compliance straightforward.

Requester Info

Full name, role, phone and email so the service provider can confirm scheduling and post-treatment notes with a primary contact.

Property Details

Exact service address, unit number, access instructions and any security or keyholder information needed for onsite access.

Infestation Description

Clear description of pests observed, affected areas, date first noticed, and any photos or evidence attachments for accurate triage.

Treatment Preferences

Checkboxes for chemical vs non-chemical options, time-of-day preferences, and any restrictions relating to pets, children, or sensitive equipment.

Authorization

Signature block for owner or authorized agent, printed name, and date to document consent and scope of work.

Billing & Warranty

Billing account or PO number, payment terms, and brief warranty or follow-up visit policy to set expectations.

Step-by-Step: Submitting an Extermination Request

Follow these four steps to submit a complete request that can be scheduled without follow-up questions.

01

Describe the Problem: Complete the infestation description and attach photos if available.
02

Provide Access Details: Give exact address, unit entry instructions, and keyholder contact.
03

Select Treatment Options: Choose permitted methods and note any safety restrictions.
04

Sign and Submit: Sign, date, and send to the provider by the method specified.

How Requests Move from Submission to Treatment

A clear routing process speeds response times and reduces the need for clarification calls.

Receive Request: Provider logs form, confirms contact info, and triages urgency.
Schedule Visit: Customer and technician agree on date/time; access instructions are verified.
Perform Treatment: Technician documents methods used, chemicals applied, and safety steps taken.
Follow-Up: Provider records results, schedules warranty visits, and updates the service record.

Digital Submission and eSignature Considerations

Many providers accept electronic submission and e-signatures; verifying authentication and record retention is essential.

File Formats: PDF, DOCX accepted
Authentication: Email link or SMS code
Audit Trail: Timestamp and IP logged

Online Form Configuration Checklist

If digitizing the form, configure these fields and settings to minimize errors and speed processing.

Field	Configuration
Requester Name	Required text field, auto-capitalize
Service Address	Required, address-verify enabled
Photo Upload	Optional, accept JPG/PNG, max 10 MB
Signature	Required, allow e-sign with audit trail

Typical Timelines and Processing Expectations

Standard response and follow-up windows help set realistic expectations for customers and operations.

Initial Acknowledgement:

Within 24–48 hours of receipt

Onsite Inspection:

Scheduled within 48–72 hours for non-emergencies

Treatment Visit:

Performed at scheduled appointment time

Follow-Up Visit:

Typically within 7–14 days if required

Warranty Period:

Varies by provider; often 30–90 days

Common Mistakes to Avoid

Incomplete address or unit number that prevents technician access and causes rescheduling.
Vague pest descriptions that lead to incorrect treatment selection and delayed resolution.
Missing authorization or payment information that stops work until owner approval is obtained.
Failure to declare chemical sensitivities or protected species leading to unsafe applications.

Short Risks and Consequences of an Incorrect Form

Delayed Service: Increased infestation risk

Unauthorized Access: Liability for improper entry

Regulatory Fine: Violation of pesticide rules

Contract Dispute: Billing or warranty denial

Health Risk: Non-disclosure of allergies

Record Gaps: Evidence unavailable in disputes

Comparing eSignature Providers for Extermination Request Forms

Electronic submission and signing reduce turnaround time. Below is a neutral pricing and feature snapshot; signNow is listed first per provider comparison rules.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no credit card	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/yr limit	Varies	Varies	Varies

Frequently Asked Questions About the Extermination Request Form

Answers to common questions about signing, submission, and recordkeeping for the Extermination Request Form.

Need help? Contact support

Can I e-sign this form?
Yes. Under the ESIGN Act (15 U.S.C. ch. 96) and state UETA laws, electronic signatures are generally valid if intent, consent, attribution, and record retention requirements are met. Confirm provider acceptance and any consumer-disclosure needs.
Who must sign the form?
The owner or authorized agent should sign to grant access and approve treatments. If a tenant requests service, obtain owner authorization where required by lease or local rules.
Are notarization or witnesses required?
Not typically for routine extermination requests. Some jurisdictions or specific permits may require notarization for authorizations tied to regulatory filings; verify with local authorities.
What supporting documents are needed?
Attach photos of infestation, proof of ownership or authorization if not the owner, and any medical or allergy notes that affect permitted treatments.
How do I cancel or revoke a request?
Notify the provider in writing and retain confirmation. For electronically signed requests, follow the provider's revocation procedure and maintain records showing the cancellation.
How long should I retain completed forms?
Keep completed forms for the active contract term plus at least three years; industry or federal rules may require longer retention (see IRS and OSHA guidance).

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