Please complete the form online, use the "Print" option from
the browser's "File" menu to print a hard copy. Sign the application
and mail the paper copy to Raincoast Water,
8621 S. 212th St, Kent WA 98031, or fax to (253) 872-9955.
Effective Date:
Source:
Rt #:
Sales Rep:
Name:
Contact Person:
Address:
City:
Address(line 2):
State:
Address(line 3):
Zip:
Home Phone:
Fax:
Business Phone:
Email:
1. Water Service: Size, Type & Price
5-Gal
(type) at $
/bottle
3-Gal
(type) at $
/bottle
1/2-Gal. Ret
(type) at $
/bottle
3. Packaged Water
(quantity)
(size)
(water type)
Please Deliver
case(s) of
Please Deliver
case(s) of
Please Deliver
case(s) of
packaged water per delivery
(customer may cancel packaged water delivery at any time)
5. Payment Information
Name (as it appears on card):
Billing Address:
Apt/Suite:
City:
State:
Zip:
Type of card:
MC
Visa
Credit Card #:
-
-
-
Expiration Date:
/
Recurring Credit Card Payment
Cust. Init.:
One-Time Credit Card Payment
Cust. Init.:
6. Initial Payment Method
Pre-Paid Amount $
Date
Method:
Check
Cash
Credit Card
Balance Due Upon Initial Delivery: $
2. Water Cooler: Item Number & Price
Room Temp/Cold (Flr),#
$
/invoice
Room Temp/Cold (Ctr),#
$
/invoice
Hot/Cold (Floor),#
$
/invoice
Hot/Cold (Counter),#
$
/invoice
Crock,#
$
/invoice
Other
4. Initial Term of Agreement
3 Years
1 Year
Period-to-Period
Water Cooler Rental & Water Service
Water Service
Bottle Deposits: A $6.00 deposit will be charged on each 5 gallon and 3 gallon bottle delivered.
All bottle deposits are refunded upon return of the empty bottles in good condition.
Cancellation Fee: If Customer terminates service during the initial Term,
Customer will be charged a $35.00 administrative cancellation fee.
Late Fee: See Section 5 of the Terms and Conditions.
Returned Check Fee: $25.00
See Terms and Conditions for additional information on deposits and fees.
7. Initial Delivery Information
Quantity
Item
Price
Notes:
Important Terms and Conditions. Read before Signing
SEE TERMS AND CONDITIONS FOR ADDITIONAL INFORMATION.
TERMS: This agreement is subject to credit approval and customer acknowledges that Raincoast
may obtain a credit report using the information provided in this agreement. Raincoast will arrange to
pick up the cooler(s) if the customer cancels or otherwise terminates this service under the terms of
this agreement. In that event, the customer agrees to allow reasonable access. Additional terms and
conditions of this agreement including a limitation of liability of Raincoast (the lessor) are listed
below. Delivered items to be billed at first delivery.
Terms & Conditions
Raincoast Water LLC. (Here in after Raincoast) agrees to lease to (Here in after the Customer) and to install on the Premises the Equipment for the Minimum Rental Term and thereafter on a month-to-month basis, unless this agreement is renewed by mutual consent for a further term, on the following terms:
The Customer agrees to:
Pay the Rental Payment on the Commencement Date and thereafter on the 1st of every month and in this regard authorizes Raincoast to withdraw payments pursuant to the terms on reverse: Personally Approved Payment Authorization. In the event of default by the Customer, Customer agrees to (1) reimburse Raincoast for all costs, including legal costs on a solicitor and client basis, incurred by Raincoast in enforcing this Agreement or in obtaining possession of the Equipment and (2) pay interest on all such arrears of payments at the rate of two (2%) per cent per month calculated and payable monthly (26.82% per annum) from the date of default until paid. Further, in the event a check or other negotiable instrument drawn by the Customer for payment toward this Agreement is not honored, the Customer will pay RAINCOAST administrative charge $ 25.00 per check or negotiable instrument not honored.
That in listing the Premises for sale or in making representations to prospective purchasers, to inform all potential purchasers that the Equipment is the property of Raincoast and in the event the Customer should sell the Premises in which the Equipment is contained, the Customer shall: (1) notify Raincoast by calling Raincoast sales person no Less than ten (10) days prior to transferring or giving up possession of the Premises; (2) provide all necessary information to Raincoast to determine If the new owners of the Premises are willing to assume the Lease and obligations of the Lease hereunder; and (3) permit Raincoast at his option to remove the Equipment from the premises.
Take reasonable care of the Equipment, use and operate the Equipment only for the purposes for which it was manufactured and in accordance with all operating and' or 'other instructions applied with the Equipment, pay Raincoast a reasonable amount for all repairs and/or replacements caused by the default or negligence of the Customer and not to remove or deface any marks, plates, stickers; or serial numbers on the Equipment by which such Equipment is identified as the property of Raincoast.
Permits Raincoast to enter upon the Premises where the Equipment is installed at all reasonable times to inspect or repair the Equipment;
Remove the Equipment from the Premises and not to encumber the Equipment, without the prior written consent of the Customer; and
Insure and keep the Equipment for its full insurable value and in the event the Customer fails to insure the Equipment, to reimburse Raincoast for any amounts paid by Raincoast to place or maintain insurance on the Equipment.
Raincoast shall keep the Equipment in good working order, and to make necessary repairs and/or replacement except those caused by the default or negligence of the Customer or third party.
The parties further agree that:
All bottles containing water that are delivered by Raincoast to supply the 1eased Equipment are the property of Raincoast.
The Customer assumes all the risks of an owner of the Equipment. Raincoast shall not be liable for any injuries (including death) or damages occasioned to or suffered by any person or property, and the Customer shall indemnify Raincoast against any and all claims and liability for injury or death of persons or damage, to property, caused by or happening in connection with the Equipment or the, condition, maintenance, possession, operation or use there of any other cause whatsoever, including, without limitation, the negligence of Raincoast, water leakage, condensation or fundamental breach of contract by Raincoast, subject to consumer protection act or any similar legislation in other jurisdictions, if applicable.
In the event the Customer desires to terminate this lease to completion of its term, the Customer shall pay Raincoast rent equal to (70%) of the remaining rent required under the term of this Lease and agrees to pay a fifty dollar administration fee and a ten dollar fee for any bottle that are not returned at the termination and all deposits for bottles by customer will be credited to customer's account.
That this Agreement shall not be assigned by the Customer except with the prior written consent of Raincoast.
That any notice required under this Agreement shall be in writing and may be served personally or by postage prepaid regular mail the parties 'address set out on reverse in which event the notice shall be deemed to be, received by the party to whom it is addressed on the third business day following its posting. Any party may change its address by notice to the other party.
Miscellaneous provisions:
Nothing in this Agreement nor any act of either of the parties hereto now or in the, future shall be deemed to have the effect of altering, modifying or transferring Rain coast's property or title to the Equipment, provided that the Customer may at any time purchase the Equipment by paying to Raincoast that sum derived by deducting from the Current List Price an amount equal to a maximum of FIVE (5) months rent paid by the Customer to Raincoast in the twelve (12) months immediately preceding the date of purchase pursuant to this clause.
That in the event any particular provision or term of this Agreement determined to be un enforceable or void by a court of competent jurisdiction, such provision or term shall be deemed to be unenforceable and such determination shall solely affect such term or provision and shall not, in itself, impair, render void or unenforceable to the remaining provisions, of this Agreement;
Where permitted by law, the Customer hereby waives the right to receive a copy of any fixtures notices any financing statement by Raincoast relating to this agreement or any verification statement issued by the applicable registry that relates to such financing statement.
The rights and remedies of Raincoast hereunder are cumulative and in addition to and are not in substitution for any rights or remedies provided by law.
Any single or partial exercise by Raincoast of any right or remedy for default or breach of any term, covenant or condition of this Agreement, does not waive, alter, affect or prejudice any other right or remedy to which Raincoast may be lawfully entitled for the same default or breach.
This Agreement shall be construed and interpreted in accordance with the laws of the State where the Customer is located at the time of execution of this Agreement and the parties here to attorney to and accept the jurisdiction of the courts of such state.
This Agreement shall ensure to the benefit of Raincoast and its successors and assigns and shall be binding upon the Customer and if applicable, its representatives, heirs, executors, administrators, legal representatives, successor and permitted assigns; and
All capitalized terms shall have the meaning attributed to them on the reverse.
By executing this agreement, the Customer conclusively acknowledges receipt of an executed copy of this agreement.
You acknowledge that you have read and agree to the above terms
and conditions.
Customer or Customer Authorized Representative's Signature:
