Delivery Form

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Delivery Form

You can order by Call OR Email

New Customer
Existing Customer

*=Required

Customer Name*

Email Address*

Account Name*

P.O. Box*

Customer Address*

How would you like to receive an update?
Email Mail

Contact Information

Cell Number* ( +x (xxx) xxx-xxxx )

Home Number ( +x (xxx) xxx-xxxx )

Work Number ( +x (xxx) xxx-xxxx )

This contract is subject to the terms and conditions set forth in the Annexure.
Month to Month

Type of Account Required:
Residential Account Corporate/Commercial Account

Bottled Water

CI $7.00 per 5 gallon, CI $10.00 deposit per bottle

Initial Order:

Initial Deposit ($):

CI $5.00 per 3 gallon, CI $5.00 deposit per bottle

Initial Order ($):

Initial Deposit ($):

If it is anticipated that more bottles will be required for the following delivery cycle, the Customer may order online, by phone and/or through the delivery driver at the time of delivery.
For any additional bottles, the deposit must have been paid in advance or at time of delivery for the order to be processed, unless the Customer has provided a Direct Debit authorisation.

Do you require a cooler to rent:
Yes No

Cold Cooler
Lease: CI $10.00 / Month (6 month prepayment required CI $60.00) Purchase: CI $275.00

Initial Order:

Initial Prepayment ($):

Hot & Cold Cooler:
Lease: CI $15.00 / Month (6 month prepayment required CI $90.00) Purchase: CI $300.00

Initial Order:

Initial Prepayment ($):

Porcelain Crock Pot (Room Temperature)
Purchase: CI $45.00

Flow Jet
Purchase: CI $175.00

Hand Pump
Purchase: $25.00

Bottle Buddies (3 stack rack for bottles)
Purchase: $60.00

Upload File (Maximum upload file size: 10 MB)
(Allows only .txt, .jpg, .jpeg, .png, .gif, .pdf, .docx, .doc, .odt, .xls, .zip files)

I agree to Terms & Conditions

*=Required

Name*

Email*

Contact Number* ( +x (xxx) xxx-xxxx )

P.O. Box Address*

Physical Address*

Select

5 GALLON

DISPENSER RENT PURCHASE

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