Click here to print our delivery contract, or fill out and submit the form below.
Account Name:*

E-Mail:*

Address of Account:



Account Phone:

Manager/Owner Name:
 Date Signed:

Billing Address:



Billing Phone:

Bookkeepers Name:
JOB INFORMATION
Pool Size:   x     Spa Size:   x    (If uncertain - approximate size is acceptable)
Name of person who shall be placing your orders:     Phone: 
Would you like automatic chlorine deliveries?:  Yes     No
    If no Automatic Delivery, please allow 2-3 Business Days Advance Notice.
Do you intend to utilize AutoChem Corp. for other chemicals and equipment deliveries?:  Yes     No
Do you have Tank(s) to store the liquid chlorine in?:    Yes     No        Quantity:      Size: 
Do you have Carboy(s) to store the liquid chlorine in?:    Yes     No        Quantity:      Size: 
Where are your Carboy(s)/Tank(s) Located?:
Do we, AutoChem Corp. have an easy access to your Carboy(s)/Tank(s):
Yes:
No:
Do you have locked gates or doors preventing us from delivering at any time?:
Yes:
No:
  If yes, please indicate gate/lock combination or location of key: 
Do you have specific dates and/or times you can accept our deliveries?:
Yes:
No:
  If yes, please indicate them: 
Please indicate the date the swimming pool shall be summerized (Subject to separate contract) (opened): 
Please indicate if you would like an opening contract: 
   Commencement Delivery Date: 
Please indicate the date the swimming pool shall be winterized (Subject to separate contract) (closed): 
   Last Delivery Date: 
Please indicate the date the establishment (account name) shall be closed: 
Sales Tax Exempt?:
Yes:
   No:
(If yes, we will require a signed exempt form)    Exempt #:

By clicking submit, you acknowledge receipt of the material safety data sheets (available on this website) and recognize the importance of furnishing all pertinent staff members with this information. You further acknowledge that all the information you have furnished on this contract is accurate and true. You acknowledge to have read all of this agreement, and hereby agree to all terms and agreement set forth by this agreement.


I have read and agree to the full conditions of this agreement*:

COMPANY SHALL NOT RENDER ANY SERVICES FOR YOUR SWIMMING POOL WITHOUT THIS AGREEMENT BEING COMPLETED, SIGNED BY A MANAGER/OWNER AND SUBMITTED TO AUTOCHEM CORP. IN ADVANCE.
 631.283.7398 info@autochemcorp.com