New Customers Name* First Last Email* Phone*Pool Address* Street Address Address Line 2 City ZIP / Postal Code Is your Pool Address and Billing Address the same?*YesNoBilling Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Weekly Price*$47.50 Full Service$32.50 Just ChemicalsHow Did You Hear About Us?Billing InformationIf you would like to sign up for automatic billing, please complete the Credit Card form below. If you want your credit card charged only when you account balance is over 30 days old, please mark the frequency for balance over 30 days. All requested information is required. Upon approval, we will automatically bill your credit card for the amount indicated and your total charges will appear on your credit card statement. You may cancel this automatic billing authorization at any time by contact us. I authorize Blue Water Express to automatically bill the card listed below as specified:Billing Date*1st of the Month15th of the MonthType of BillingYou may choose monthly billing or Past Due 30 Days. Choosing monthly will allow us to charge your card monthly for our services. If you prefer to send in a check, select Past Due 30 Days. Your credit card information must be entered and on file even if you plan to pay via check. In the event your account is more than 30 days past due, we will charge the card on the account.Type of Billing*MonthlyPast Due 30 DaysCard Type*VisaMastercardDiscoverCard Number*Expiration Month*010203040506070809101112Expiration Year*CVC (3 Digit Code)*Name of Card Holder* Card Holder ZIP*Start Date Date Format: MM slash DD slash YYYY CommentsSignature*Please verify your information is correct. Use the submit button at the bottom to complete your update. NameThis field is for validation purposes and should be left unchanged.