CUSTOMER INFORMATION

Billing Address (include complete address):

Primary Contact Please include Area Codes for the country & city

Logistic Contact

Accounts Payable Contact

Service Contact

SHIPPING CONTACT INFORMATION

Freight Forwarder Contact Information:

Special Shipping Instructions (please check all that apply):

Backorder Status (please check one of the following):

Other Comments:

NOTE: please provide a copy of an ID and resale tax certificate

Electronic signature:

By selecting the "I Accept" and putting your name, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

I Accept (put an X to select this)