Billing Application

Corporate or Official Name *

D.B.A.

Billing Address *

Address Line 1

City

State

Zip Code

Phone Number *

Billing Email Address *

We only offer email as a billing option.

Tax Exempt? *

Yes
No

Tax Exempt Form *

Click or drag a file to this area to upload.

We have a button to download the Minnesota Tax Exempt form at the bottom of this screen.

Date Business Began *

Has this business declared bankruptcy? *

Yes
No

If yes, please explain *

Has any company which you owned ever declared bankruptcy? *

Yes
No

If yes, please explain *

Do you have any pending lawsuits against you? *

Yes
No

If yes, please explain *

Would you like us to reach out to you to provide a quote for all repairs that will cost more than the service charge, or would you like to give us an amount that you would like to pre-authorize? *

Reach out to me to provide a quote for all repairs that will cost more than the service charge
We authorize you to repair a unit as long as the total repair cost is under the specified amount below (including service charge)

Pre-Authorized Amount *

Commonly, businesses choose $450 as a pre authorized amount. Any time we exceed that amount on a repair, we will reach out to you to see if you would like to move forward with the repair.

Name of person in charge of authorizing repairs *

First

Last

Email address for person in charge of authorizing repairs *

Phone number for person in charge of authorizing repairs *

How many appliances do you expect to schedule for service with Omega Force each year? *