A Royal Flush, Inc.

Name:

Effective Date:

Street#:

Street Name:

City:

State:

Zip:

Location:

Phone#:

Service Contact:

Fax#:

Name:

Term:

Street#:

Street Name:

City:

State:

Zip:

PO#:

Credit Reference

Phone#:

Billing Contact:

Fax#:

Credit Card#:

Additionl Instructions :

THIS AGREEMENT IS A LEGALLY BINDING CONTRACT ON THE PART OF BOTH A ROYAL FLUSH INC. AND CUSTOMER AND THEIR RESPECTIVE HEIRS, SUCESSORS AND ASSIGNS IN ACCORDANCE WITH THE TERMS AND CONDITIONS ON THE REVERSE SIDE IN THE EVENT THAT THE AGREEMENT IS NOT SIGNED, PAYMENT AGAINST ANY INVOICE SHALL CONSTITUTE AGREEMENT TO THESE TERMS.