EmailMe Form - Customer Service Information Sheet

*

New Customer

Change in Customer Info

Today's Date *

MM / DD / YYYY

Sales Rep

Requested Date of First Delivery

MM / DD / YYYY

Terms desired *

COD

Credit Card

Net 15

Net 30

Account Name *

Shipping Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Contact Name

First Last

Requested Call Day

Requested Delivery Day

Receiving Hours/Shipping Instructions

Type of Business

AR Contact

First Last

Phone

### - ### - ####

Fax

### - ### - ####

Email

Optional

Web Site

Billing Address (If different from above)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Default Price Level *

Tier 1

Tier 2

Tier 3

Other

Type of Products

Est. monthly volume of item placed.

(Separate equipment request or sales order must be submitted prior to install)

Summary: