Brookcrest by Culligan — Bottled Water Service Agreement

Step 1 — Customer Information

Business Name (optional)

Contact Name *

Contact Phone *

Ext

Delivery Address * Email Address *

Order Date *

Requested Service Date

Leave blank for ASAP

Please fill in all required fields.

Step 2 — Water Products

Enter the number of bottles per month for each water type you need.

5 G Distilled Water ($13.39/bottle)

5 G Drinking Water ($9.79/bottle)

5 G Spring Water ($11.39/bottle)

Case Water 24 x 0.5 Liter ($9.99/case)

3 G Drinking Water ($8.29/bottle)

3 G Spring Water ($10.69/bottle)

Delivery

Deliveries per Month *

Dispensers

Hot & Cold Coolers ($10.50/mo each)

Cook & Cold Coolers ($10.50/mo each)

Bottomload Coolers ($13.95/mo each)

Bottle Deposit — auto-calculated at $6.00 per bottle per delivery

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Notes

Order Notes Delivery Instructions

Representative

Representative Name

Please enter at least one water product.

Step 3 — Review Your Agreement

I have read and agree to the Terms and Conditions. By checking this box I acknowledge that I am authorized to request service on behalf of the business listed above.

Please review and accept the Terms and Conditions to continue.

✓ Sent

Your agreement has been sent.

Sign Your Bottled Water Service Agreement

Review the summary below, then sign to authorize Brookcrest by Culligan to begin your bottled water service.

I have read and agree to the Terms and Conditions. By checking this box I acknowledge that I am authorized to sign this agreement on behalf of the business listed above.

Please review and accept the Terms and Conditions to continue.

Customer Signature

Print Your Name *

Date Signed *

Please sign above and enter your printed name to continue.