New Customers

Please fill out the form below to receive your customer login credentials. Call us at (269)-208-6178 if you need assistance or have any questions. Thank you!

Billing/Shipping Info:

Official Company Name

Billing Address

Shipping Address

Main Phone

Main Fax

Email

Business Info:

If division or subsidiary, name of company

Years in Operation

Type of business

Tax ID - Please send copies of all tax exempt certificates

President

Manager

Bank Info:

Bank

Contact

Account No.

Bank Phone

Complete Bank Address

Trade References:

Reference 1

Reference 1 Name

Reference 1 Contact

Reference 1 Main Phone

Reference 1 Main Fax

Reference 1 Email

Reference 2

Reference 2 Name

Reference 2 Contact

Reference 2 Main Phone

Reference 2 Main Fax

Reference 2 Email

Reference 3

Reference 3 Name

Reference 3 Contact

Reference 3 Main Phone

Reference 3 Main Fax

Reference 3 Email

Prepared by (name)

Title

Date

By using this form you agree with the storage and handling of your data by this website. You also agree that this allows Great Lakes Tackle to send you emails.