*Business Name:
*Date:
*Contact:
Sales Person:
*First Name:
Last Name:
*Delivery Address:
Mailing Address:
City / State:
Zip Code:
*Home Phone:
*Business Phone:
*Cell Phone:
*Email Address:
*Start Delivery Date:
Payment Method
cash
credit card
paypal
check
5 Gal. Water Delivery 5.99 each
Credit Card Information:
Card Type
Master card
Visa
Credit
Debit
Cooler Rental $10.00 a month each
Bottles Requested:
2
3
4
others
*Name on Card:
Delivery Frequency:
2weeks
others
*Billing Address:
I agree to the terms & conditions
as shown on the back of this agreement.
*Card Number:
*Signature:
*Expiration Date:
Real Water PO Box 310 Walker, La. 70785
Phone 225-667-4500 Fax 225-664-3555
