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• <br /> 1ISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# KAREN DEMMERS /1530 EXT 7170 DATE 11/06/12 <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 /> BUSINESS PHONE# / CELL # <br /> FAX NUMBER <br /> SSN OR TIN /EIN# <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 <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 SLH7 /ADD AMOUNT TO BILL 4.15x15.00 = 62.25 MONTH <br /> RATE TO BE USED AMOUNT TO BILL <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 /> 15 STREET LIGHT ON ALEXANDER LOOP <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 3 -6 -13 DATE ENTERED 3 -7 -13 <br /> ENTERED BY EW2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br />