Service Request Agreement - Nationwide Security Service

**Valued Clients Please be advised that any cancellation of service within less than a 24 hour notice will result in a 6 hour minimum cancellation charge.** Any Service Request being made in less than 24 hours of the start time of an assignment shall be considered EMERGENCY SERVICE and emergency rates will apply.**
Today's Date*
Date Format: MM slash DD slash YYYY
Your Email*
Would you like to send a copy of this request to another email address ?*
Email a copy to:*
Company / Chain Name*
Your Title*
Name*
First Last
Office Phone*
Cell Phone*
Company Address*
Street Address City State ZIP Code
Billing Contact*
Billing Phone*
Billing Email*

Where Service is Needed.*
Address Where Service is Needed*
Street Address Address Line 2 City State ZIP Code
Site Contact*
Site Contact Phone*
Number of Guards Needed*
Service Type*
Start Date*
Date Format: MM slash DD slash YYYY
End Date*
Date Format: MM slash DD slash YYYY
Start Time*

: HH

MM
End Time*

: HH

MM
Job Completion Date*
Date Format: MM slash DD slash YYYY
Additional Dates & Time.
Day Date Time In Time Out

Use the + to add more.
Reason Security is Needed and other directives.*
Do you have any files to share with us?*
- Yes
- No
Please upload your files*
Drop files here or

Accepted file types: jpg, gif, png, jpeg, pdf.

Who is the person filling out this form*
I have a rate agreement for service.*
- Yes, Per Hour Rate
- Yes, Flat Rate
- No
What is your agreed rate amount ?*
Privacy Policy*
I have read and agree to Nationwide Security Service's privacy policy.
https://nationwidesecurityservice.com/privacy.html
Payment Terms*
I have read and agree to Nationwide Security Services payment agreement.
https://nationwidesecurityservice.com/terms-conditions-service.html
Cancelation Terms*
I have read and understand the cancelation policy.
** Any cancellation of service within less than a 24 hour notice will result in a 6 hour minimum cancellation charge.** Any Service Request being made in less than 24 hours of the start time of an assignment shall be considered EMERGENCY SERVICE and emergency rates will apply.**
How would you like to pay ?*
- Please bill me
- Down payment with a credit card.
- Pay in full with a credit card.
Please sign.*

Day	Date	Time In	Time Out