New Search
. • f IPIF <br /> • • <br /> MISCELLANEOUS BILLING REQUEST FORM <br /> ORIGINATOR'S NAME /EW# FATOOH /2384 EXT 7596 DATE 07/18/2012 <br /> NEW ACCOUNT SETUP ❑ ADJUSTMENTS & CHARGES X <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) 10 / <br /> BUSINESS INFORMATION <br /> TYPE OF BUSINESS (COPR, LLC, ETC.) I e w <br /> OWNERS LEGAL NAME & SSN <br /> ACCOUNTS PAYABLE t/0 <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 /> COE JOB# 4698, EWEB JOB #36153, EWEB DWG # B -26750 <br /> ADJUSTMENTS AND CHARGES <br /> RATE TO BE USED SLH1 /REMOVE AMOUNT TO BILL ( 5.15) X 10 = (51.50) /MONTH 100tAJ <br /> RATE TO BE USED SLH1 /ADD AMOUNT TO BILL 5.15 X 4 = 20.60 /MONTH / CAA-) RATE TO BE USED SLH7 /ADD AMOUNT TO BILL 4.15 X 8 = 33.20 /MONTH W <br /> ACCOUNT NUMBER 23736 -142 BUNCH CODE TO BE USED <br /> NOTES (REASON FOR ADJUSTMENT, ETC.) <br /> UPGRADING LIGHTING FACILITIES. <br /> BILLING CONTROL USE ONLY <br /> DATE RECEIVED 4 -1 -13 DATE ENTERED 4 -1 -13 <br /> ENTERED BY EW2036 CYCLE NUMBER 01 <br /> ACCOUNT # 23736 -142 ADJUSTMENT # 100423970 <br />