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

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