Customer Order Service Request

Please place your Service Order Request by completing and submitting this form. Except for emergencies, our service calls have a 2-3 day lead time and scheduled on a first-come basis.

Service Request

First Name:*

Last Name:*

Business Name:*

Account Number:

Business Telephone:*

Customer P.O.:

Email Address:*

Service Authorized By:*

Service Location Name:*

Service Location Address:*

Service Location City:*

Service Location State:*

Service Location Zip Code:*

Service Location Contact:*

Service Location Telephone:*

If Billing Address is Different from Service Location, please fill the portion below:

Billing Address:

Billing City:

Billing State:

Billing Zip Code:

Account Payable Contact:*

Account Payable Phone #:*

Account Payable Email:*

Description of Service Request:*

Required: Customer is responsible for an agrees to all fees associated with this service call. The venue for any disputes involving Secure it Securities Corp will be New York State. Any payment not received by the due date (per invoice) will be subject to an 18% APR (1.5% monthly) late charge. The customer agrees to pay all fees necessary to collect any past due amounts including but not limited to the amount due, late fees, attorney fees, and any other reasonable expenses incurred to collect this debt. Click here for standard billing rates.

Check YES if you agree with the statment above:*

YES

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