Company Name:
Customer #:
If you don't know your customer #, please enter your city and state so that we can correctly identify your store.
City:
State: 
Your Name:
Your Phone:
For each of the following, please choose whether you'd like to receive your notifications/documentation electronically and if so, provide the fax number or email address to receive that document type.
Choose Email or FAX for the following confirmations:
Fax Number:
Order Placement Notification:
Order Placement E-Mail Address:
Order Shipping Notification:
Order Shipping E-Mail Address 1:
2: (separate any additional addresses with a comma)
Customer Pickup POD Signature:
Electronic Invoice:
Fax E-Mail
Would you like to be contacted about using our new 24/7 Online Ordering Website?
May we use the email address above in the order or shipping notification area to send you occasional new product announcements, inventory closeouts, or other special information?Yes No
Alternate email for announcements:
(optional)
Additional email address 2:
Additional email address 3: