I. ACCEPTANCE

The client accepts the terms and specifics of this agreement and acknowledges that there are no other outside agreements. This document is the entire agreement.

(SIGNATURE)

I Accept the Responsibility of Payment:

PRINTED NAME:

Social Security Number:

LOCATION OF ASSIGNMENT / DIRECTIONS:

BILLING INFORMATION:

Address:

GENERAL DESCRIPTION / SCOPE OF WORK

Day Phone

Evening

Phone:

FAX

E-Mail

No appointments will be scheduled until all portions of this page are filled out, this page is returned to us, and the fees for the Visual Inspection and Verbal Report are received or we agree, in advance, to accept payment at the time of the inspection.

No Report or other work product will be released, mailed, or faxed until payment in full is received.