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: CorporationPartnershipProprietorshipSubsidiaryDivision 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.