Disinfect & Fog Agent Form - Monthly Disinfectant Kit
After the form below is submitted, we will invoice the client and send them the contract.
AGENT Name: *
AGENT Email: *
Client Business name:
Client name: *
Client Email: *
Client Phone number: *
Client Shipping Address: *
Client City, Province, Country: *
Client Postal code: *
Type of Business: *
Select one...
Automotive
Business
Child Care
Community Centre
Dental
Education
Entertainment
Funeral Home
Government
Healthcare
Hospitality
Industrial
Place of Worship
Real Estate
Sports + Recreation
Transportation
Tourism
Travel
Veterinarian + Animal Care
Other
If other, enter Below:
Payment method: *
Select one...
Credit Card
Cheque
E-Transfer
Client Billing Address (if different from shipping address):
What DEVICE do they want?
Disinfecto Cordless Electrostatic Sprayer
Nano Atomizer
Portable Fogger
Additional information (optional):
Thank you!
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