Septic Service Application Form

Septic Service Application Form

Agreement Recitals

WHEREAS, Provider Name: is engaged in the business of providing septic system maintenance, inspection, repair and pumping services; and

WHEREAS, Applicant Name: requests septic services for the Property described below and agrees to be bound by the terms set forth in this Application and Service Agreement.

NOW, THEREFORE, in consideration of the mutual promises contained herein, Provider and Applicant agree as follows:

Application Details

Property Information

Service Property Address:

Approximate tank capacity (gallons):     Last pumped or serviced on:

Is there locked access to the tank? Yes No    If keys are needed, provide location or instructions:

Service Requested

Scope of Work

Payment Terms

Service Fee: $

Payment Schedule:

Late Payment: In the event of late payment, Applicant agrees to pay interest of on overdue balances and to reimburse Provider for collection costs, including reasonable attorney fees.

Term and Termination

Term Commencement Date:     Term Expiration Date (if applicable):

Either party may terminate this Agreement for material breach after providing written notice and a cure period of days. Termination shall not relieve Applicant of payment obligations for services already performed.

Confidentiality

Both parties agree that technical information, pricing, and other non-public business information exchanged in connection with this Application and Service Agreement shall be treated as confidential and shall not be disclosed to third parties except as required by law or with the prior written consent of the disclosing party. Confidential information does not include information that becomes publicly available through no fault of the receiving party.

Insurance and Liability

Provider shall maintain general liability and worker's compensation insurance in amounts customary for the industry. Applicant shall maintain homeowner or commercial insurance covering the Property. Provider's liability for any claim arising out of services provided shall be limited to the greater of (a) the total fees paid by Applicant for the specific service giving rise to the claim, or (b) Provider's available insurance proceeds.

Governing Law

This Application and any resulting Service Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict of law principles.

Entire Agreement

This Application, together with any written scope of work and payment schedule signed by the parties, constitutes the entire agreement between Provider and Applicant regarding the subject matter hereof and supersedes all prior oral or written agreements and understandings. Any modification must be in writing and signed by both parties.

Certification and Authorization

By signing below, Applicant certifies that all information provided in this Application is true and accurate to the best of Applicant's knowledge, authorizes Provider to access the Property to perform the requested services, and acknowledges responsibility for payment in accordance with the Payment Terms above.

Emergency Contact Name:    Phone:

Applicant Authorization (check to authorize): I authorize Provider and its authorized representatives to enter the Property and perform the services described herein, and to take photographs and records necessary for the work and for Provider's files.

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