Customer Contract Worksheet Customer InformationCompany Name* Contact Name* Name Email* Phone*Cell PhoneURL Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing TermsBilling Date: 1st of MonthPayment Terms: Due Upon Receipt Payments not received within 30 days will be charged interest at 2% per monthPayment Method* Credit Card Bank Routing Routing # Account # Credit Card Number Name on Card Exp. Date CVC Number Do You Have A Different Billing Address? Yes No Billing Address (If Different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ServicesServices* Foundation Package Foundation Plus Package Social Media Package Pay Per Click Management Pay Per Call Website Design & Development Local Listing Management (a la carte) Call Closing Services Custom Package # of Locations for Selected Package* Price Per Location* Price* Set-Up Fee* Set-Up Fee* Custom Package Includes* Foundation Package Foundation Plus Package Social Media Package Pay Per Click Management Pay Per Call Website Design & Development Local Listing Management (a la carte) Call Closing Services Set-Up Fee* Set-Up Fee* Pay Per Click Monthly Budget* Cost of Website Design & Development* Additional DetailsContract Term: 1 year with a 60-day cancellation Contract Execution Date* MM slash DD slash YYYY Terms of Service AgreementAgree to Terms of Service Agreement* I have read and agree to the CallBlu Terms of Service Agreement. Additionally, I authorize payment processing to CallBlu. View Terms of Service AgreementSignature*
