PORTABLE TOILET ORDER FORM
* Required Fields
Agent Long Term?
* Req. Service Date   
Call First? * Pick Up Date   
* Name
Delivery Address
Nearest Cross Street
Township County
Will someone be home? Who?
Driver Directions and Placement
Work Phone Cell Phone
*Home Phone Fax
Mailing Address
as above
* Email
Payment Driver Pick Up Payment on Delivery?
Note:  If you choose to pay by Credit Card, someone from our office will contact you for your Credit Card information.
Specify quantity and type
Specify quantity and type
Tax Exempt? If Yes, Exemption Number
Cleanings per Week Cleanings per Month
Pricing Short term (1-30 days): Reg $125  Sink/Sanitizer $150  Flush $175  ADA $175
Pricing Long term (60+ days):   Reg $100  Sink/Sanitizer $125  Flush $150  ADA $150
Construction Prepaid Reg $300 Sink/Sanitizer $375
Add 7% tax

Service Agreement

I understand that the unit must be located to allow access for service and that inclement weather may impact the ability to service the unit.  Only the agreed number of services will be attempted.  If a second attempt is requested, a re-attempt charge of $15.00 will be charged.  I understand that if the unit is placed too far off the driveway, it may not be possible to access it for cleaning or pickup without damaging the grounds.

I represent and warrant that I am the owner or the duly authorized agent of the owner(s) of the premises and accept responsibility for the unit while it is on site.

By accepting the portable toilet/restroom and services, I acknowledge that in the event my account is referred to a collection agency or attorney for non-payment of my balance, I will be responsible for all costs associated with such action.  These will include all attorney fees, court costs, interest on the unpaid balance, collection fees and any other such cost incurred to make English Portable Sanitation, LLC whole for the work performed.  I personally guarantee payment of the account.  I represent and affirm that I have read this waiver and understand and consent to its terms.

I represent and affirm that I am of legal age and can contract in my own name.

By clicking the "Submit" button below, I agree to this Service Agreement.

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