All items marked with an * below are required to submit the form. Please be sure to fill them out completely.

Customer #

*Name:  *

*Address:  *

*Town:  *

*Zip:  *

*Home #:  *

*Daytime #:  *

*Email :  *

Please add my name to your e-mail list for future septic cleaning reminder notices.

I am already a Plumber-Rooter / Kaiser- Battistone customer.

Please tell us how you heard about us: Friend or Relative  Mailing  Newspaper  Radio  Reminder Notice  Searching the Internet  Google  Yahoo  Trade Show  TV  Val Pak  Web Site Link  AT&T  Yellow Book  Other 

Section 2.)

The only payment accepted will be credit card. [we utilize secure servers, your credit card information is encrypted.]

Please make payment for 11 months of KB-X-TENDR at $12.25 per month -- $134.75 plus $10.95 shipping and handling and $9.25 sales tax for a total of $154.95

Billing Address if Different than in Section 1

Credit Card Type:   Visa  Mastercard  American Express  Discover 

Credit Card Number:

Expiration Date (mm/yyyy)

Thank you for being a Kaiser-Battistone Internet Customer. We appreciate your business.