Your Company Name Pest Control

Address Contract • Service • Renewal

City, State Zip
Phone Number

SERVICE INFORMATION BILLING INFORMATION

Date: Time In am pm
Contract Renewal Service Exp. Date:
Time Out am pm
Customer Name: Name:

Service Address: Billing Address:

City: St. Zip City: St. Zip

Home Ph: Home Ph:

X
Work Ph: Work Ph:

A
TYPE OF SERVICE

M
Service Fee
Commercial New Termite Job Cust. Req. Insp.

N
Residential Odd-Job Termite Initial Service Sales Tax

W
Pest Renewal Termite Renewal Regular Service

O
Odd-job Pest Termite Transfer Flea Treatment
Total Amount
Six-Month Follow-up Termite Retreat Ant Treatment

R
Pest Control Sub Termite Renewal Other

C
Payment Rec
Yard Control Rodent Control
MATERIALS USED
% NAME / EPA # AMOUNT % NAME / EPA # AMOUNT % NAME / EPA # AMOUNT % NAME / EPA # AMOUNT
TEMPO 20WP WASP FREEZE PROCIDE FOGGING AVERT COCKROACH
EPA 3125-380/396 EPA 499-362 7338 EPA 1021-1424 GEL BAIT EPA 499-410
DEMAND CS PERMA DUST ULD BP-100 PETCORE EPA RG
EPA 100-1066 EPA 499-220 EPA 499-452 NO. 2724-404-50809
DIAZINON GRANUALS ORTHENE ULD BP-300 PRECOR

E
EPA 4-272 EPA 499-373 EPA 499-450 EPA 2724-352
DELTA DUST DRAX ANT KILL GEL KILLMASTER TIM-BOR

L
EPA 432-772 BAIT EPA 9444-131 EPA 26693-2 EPA 1624-39
VAPON 20% SIEGE ANT BAIT QUINTOX RAT/MOUSE

P
EPA 655-492 EPA 241-313 BAIT EPA 3240-42-1255
FICAM D ADVANCE GRANUALS QUINTOX MOUSE SEED
EPA 45639-3 EPA 499-370 PAC EPA 3240-28-1255

AM
CB 80 DUAL CHOICE BAIT WEATHER BLOK-XT
EPA 9444-175 STATIONS EPA 499-459 EPA 10182-339
ENGAGE AVERT COCKROACH
EPA 499-292 BAIT EPA 499-406

S
Place a check mark by each target pest:
Fire Ants Brown Recluse Spiders Spiders Fleas Ticks
Carpenter Ants Black Widow Spiders Carpet Beetles Pill Bugs Other
Pharaoh Ants American Roaches Earwigs Sowbugs Other
House Ants Oriental Roaches Crickets Subterranean Termites Other
Silverfish German Roaches Roof Rats Wasps Other
Scorpions Brown Banded Roaches Norway Rats Yellow Jackets Other
Firebrats Smokey Brown Roaches House Mice Bees Other

TREATMENT AREAS * APPLICATION METHOD TREATMENT AREAS * APPLICATION METHOD

Kitchen/Dining Rm Attic
Living Room Closets
Bedrooms Wall Voids
Bathrooms Exterior
Garage/Storage Yard
Basement/Crawl Spaces Offices
Other Other
COMMENTS:

Serviced by Date

Customer Signature Date

Reorder Product # 7032 From • CROWNMAX • 1-800-252-4011