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• <br /> •MISCELLANEOUS BILLING REQUEST FOR• <br /> ORIGINATOR'S NAME /EW# Lowen/ 2294 EXT 7443 DATE 2/04/2013 <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 /> No) <br /> CONTACT NAME <br /> BUSINESS PHONE# / CELL # <br /> FAX NUMBER n <br /> SSN OR TIN /EIN# \ V/ <br /> REFERENCE INFORMATION 6/ <br /> FULL LEGAL NAME, RELATIONSHIP <br /> COMPLETE ADDRESS v <br /> PHONE(HOME, BUSINESS,CELL) 1 P <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) <br /> OWNERS LEGAL NAME & SSN �1� <br /> ()V <br /> 4.1 <br /> ACCOUNTS PAYABLE <br /> PARTNERS (FULL LEGAL NAMES & SSN <br /> 110 c \ <br /> CORPORATION OFFICERS f l <br /> TITLE, FULL LEGAL NAME(S) <br /> ADDRESS <br /> PHONE (HOME, BUSINESS, CELL) <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 -5.15 X 3 = - $15.45 <br /> RATE TO BE USED Increase SLH7 AMOUNT TO BILL 4.15 x 3 = $12.45 <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 (3) 100 W HPS S/L @ 34 & Grant COE pole 26925, 1800 Lemming Ave COE P27304, 2566 Cubit <br /> COE P 98497 w/ (3) 70 W HPS effective 1/18/2013 <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED DATE ENTERED <br /> ENTERED BY CYCLE NUMBER <br /> ACCOUNT # ADJUSTMENT # <br />