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