ONLINE CUSTOMER APPLICATION

Name:
Address:
Phone number:
Alternate number:
Type of Cover System:
Purchased/Installed by:
Year of Installation:
Refered by:
Problem/Service Needed:
PLEASE NOTE: Your credit card will be charged immediately for services rendered.  You agree, if for any reason you dispute any charges with your credit card company, and your account is sent to collection, you will pay the costs of collection. A 1.5%, per month, service charge will be assessed for all payments not made immediately.
Card Holders Name:
Credit Card Number:
Exp. Date:
Authorized Amount:

There will be a charge for the visit even if we are unable to complete the repair because parts need to be ordered.  You do not receive a new warranty for your system if we make a repair to it.  If any parts are replaced under the manufactuer's warranty, you will still be responsible for labor and/or shipping charges. Please note that we charge for travel time one way.  Gas surcharge will also be applied.  Our hourly rates are $140.00 per hour. ($190.00 for Saturday service)  Please also be aware that we charge $250.00 to lift and replace motor end stones that are over 4' long x 2' wide x 2" thick for service, provided they are not cemented in place. 

 By clicking submit, you agree to the terms of this customer application and agree to have your credit card charged for services provided.

American Pool Safety Specialists, Inc • 40 Wakeman St, Bridgeport, CT 06605 • Phone (203) 335-2049 Fax (203) 335-2063
Home Improvement Registration #540848, 549586 • Westchester WC-12264-HO1