HVAC Service Agreement Sign Up Form

Please fill out all fields of the form and click “Submit Information” button at the bottom.
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Choose Desired Plan (required)

Number of systems to get coverage (required)

System Type:GAS/ELECTRICBOILEROIL
Existing Customer?NoYes

Full Customer Name (required)

Service Address (required)

Service City (required)

Service ZIP Code (required)

Your Email (required)

Your Phone (required)

Preferred Contact Method (required)

Cardholder

Credit Card Number

Expiration DateCVV code
Billing Address (required)

Billing City (required)

Billing ZIP Code (required)

I authorize regularly scheduled monthly charges to my credit card. I understand that this authorization will remain in effect for 12 months and month-to-month therefore until I cancel it in writing, and I agree to notify Emergency Maintenance Company, LLC in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next or previous business day. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form. I commit to this monthly service agreement for 12 months, and understand that it will automatically continue on the month-to-month basis until modified or cancelled. You may be charged by Emergency Maintenance Company, LLC the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your credit card statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.