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•ISCELLANEOUS BILLING REQUEST FORM • <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 11/07/2012 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES <br /> ACCOUNT SETUP <br /> CUSTOMER INFORMATION <br /> CUSTOMER NAME City of Eugene <br /> PRESMISES /PROPERTY ADDRESS <br /> • MAILING ADDRESS <br /> CONTACT NAME <br /> \ J / <br /> BUSINESS PHONE# / CELL # <br /> FAX NUMBER \\9 <br /> SSN OR TIN /EIN# N <br /> REFERENCE INFORMATION <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS <br /> PHONE(HOME, BUSINESS,CELL) <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> CORPORATION OFFICERS <br /> TITLE, FULL LEGAL NAME(S) \!`'� <br /> ADDRESS �I^ Th �� <br /> PHONE (HOME, BUSINESS, CELL) J /� <br /> BANK INFORMATION <br /> BANK NAME <br /> BRANCH (IE. MAIN BRANCH, EUGENE OR) <br /> AUTHORIZED PARTIES <br /> NOTES( CONTRACT #, JOB #, JOB SPECIFICS, ORDERED BY, ETC.) <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED Decrease SLH1 AMOUNT TO BILL X 5 = -25.75 <br /> RATE TO BE USED Increase SLH7 AMOUNT TO BILL 4.15 x 5 = $20.75 <br /> RATE TO BE USED AMOUNT TO BILL <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> Per Jim Riggs @ COE repl (5) 100 W HPS S/L @ 2873 Applewood COE Pole 30009, 308 Van Duyn COE pole 29870, 1617 <br /> Crescent COE Pole 30612, Willona &Erin Way COE pole 30623, & 575 W 40 COE pole 98615 w/ (5) 70 W HPS effective <br /> 10/19/2012 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 11 -7 -12 DATE ENTERED 11 -7 -12 <br /> ENTERED BY ew2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100156172 <br />