New Customer or Change to Acct #      with  Add’l Address   Change to existing information


Customer Name:       


Parent (Main) Address:    Bill to this address     Bill to ship to address


Address line 1      

Address line 2      

                        City           State      Zip       -      County       (please provide if known)     


            Attn:        (should use Accounts Payable unless customer instructs otherwise)


Ship To Address:  (for multipleship to addresses please send additional sheet listing addresses)


            Ship To Name:      

            (if not same as customer name)


Address line 1      

Address line 2      

  City         State      Zip       -      County      




            Payment method:  Pay by Check     Pay by Credit card only


            Credit Limit Requested $      fax credit application to Janet Simmons at (314) 372-2011


Is this a Government entity? Yes   No  Please note this on credit application as well


            Taxable?  Yes   No    fax exemption certificate to Linette Q. at (314) 372-209


            Customer Accounts Payable Contact Name:                 


Send Invoices to customer via:    E-mail       Fax        Mail 


Customer A/P Phone #:(   )                  Customer A/P Fax #:(   )      

                                                                        Required if sending invoices via fax

Customer A/P E-mail Address:      

            Required if sending invoices via e-mail


            Submitted by: 


Sales Partner Name:                Sales Partner #           Division:      


            Will commissions to this customer always be split with another partner?  Yes   No   

If yes- Sales Partner Name:         SP#         % to other partner