New Customers

Delivery Address

Name

Address

Street Address Street Address Line 2 City State Zip Code

Contact Person

First

Last

Email*

Billing Address (If different)

Billing Address

Street Address Street Address Line 2 City State Zip Code

Phone (Home)

Phone (Cell)

Phone (Work)

Delivery Instructions

Product Information

Item Description

Qty

Price each

Total

Cooler Type

Water

Cups

Other

Bottle Deposits

Order Date

Customer Type

Residential

Commercial

Referred by

Statement

Emailed

Mailed (+ $1.50 per month)

Equipment rent, setup fees, and unused water are nonrefundable.
Without Idaho Ice's consent customer will not remove/relocate the water dispenser from service address listed on this application.
Customer will take reasonable care of water dispenser and any other Idaho Ice equipment on their premises. Customer will allow Idaho Ice reasonable access to inspect Idaho Ice property located on their premises. Customer will allow Idaho Ice representative access to their residence to remove Idaho Ice property upon termination of this lease.
Customer will NOT perform service or make repairs to the water dispenser. Customer will NOT refill Idaho Ice water bottles with any other water. Idaho Ice will provide any service and maintenance to Idaho Ice equipment at no additional expense to the customer. Idaho Ice is NOT liable for any consequential or incidental damage which may arise out of customers use of water dispenser and/or water service including fire, water, or electrical damage.
If you fail to pay your account and Idaho Ice has to turn the account over to collection you will be charge full retail of the water dispenser, if you have failed to return it to us as requested.
In the event you (the customer) default in payment for services rendered and usage of equipment in your possession, this account may be placed with an attorney and/or collection agency. The undersigned agrees to pay all attorneys fees and court costs.

Electronic Signature

Date