Fall Cleanout Payment Form Billing InformationName:* First Last 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 Phone:*Email:* Fall Pond ServiceMain Service Type:*Clean out my ENTIRE pond & all filters ($795) *ONLY clean my skimmer and biofalls ($450)* If your pond requires more than 6 hours you will be assessed an additional charge at the rate of $75/ man hour.Fall Pond Service OptionsSupply and install one net over my pond (10’X20’) Price: $250.00 Quantity: I need two nets to cover my pond, supply and install two nets Price: $375.00 Quantity: I’ll leave my own net for you to install (place net next to pond) Price: $200.00 Quantity: Divide, re-pot, change soil, fertilize lily containers $100 per pot Price: $100.00 Quantity: New!! Fall themed package (must pre-order limited supplies) Price: $200.00 Quantity: LED Light Fixture Price: $300.00 Quantity: Standard Skimmer Mat Price: $50.00 Quantity: Electronic Ionizer (prevent string algae) Price: $995.00 Quantity: Replacement ionizer probe Price: $195.00 Quantity: Although we take extra care to keep your fish safe and free of harm during your ponds clean out, we cannot guarantee their health or safety. In spring the immune systems of your fish are at their weakest and they are most vulnerable to disease, stress, injury or other physical illnesses, even death. Therefore Pondscapes of Charlotte LLC does not, at any time, take responsibility for the health or safety of your fish and will not be held liable or negligible for the health, safety or physical well-being of your fish.Coupon Code: If you have a coupon code, please enter in the code and click apply. USE COUPON CODE 'FALL10' IF PRE-PAYING BEFORE SEPTEMBER 30TH!Total Amount: $0.00 Notes:If you have any special requests, notes, or comments you would like to include, please enter them here. Special requests may be subject to additional charges.Credit Card Information:* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Expiration Date Security Code Cardholder Name Agree & Proceed By checking the box indicated, I am acknowledging that I accept and agree to abide by the terms and conditions as outlined CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.