The Complete Wholesale Line of  Terminals, Wire and Wiring Devices,  Nationwide
Automotive - Truck - Marine - Farm - Industrial		 Made in the U.S.A.
1620 32nd St.
Springfield, OR 97478
(800) 547-4711
FAX (541) 744-1173
Phone (541) 744-0630

New Account Setup Form

Source:
Salesman: Account #: __________
Discount:
Other:  Credit: __________
Terms:
Other:  Date/Time: __________
Shipping:
Hold for Rep.  or Ship Date:
  or Other:
   
Office: (Check all requests that apply)
  Computer Load Sheets
  Disk w/all Inventory
  Disk w/Purchases only
 
Email w/all Inventory Email address (if checked)
 
Email w/Purchases only
 
Fax copy of Invoice to ... (Fax #)
  Office Approval Needed
  Extra 5%
  60 Day Dating
  30-60 Day Billing
Ship To:
Name: Phone:
Street: Fax:
City: State: Zip:    
   
Bill To:
Name: Phone:
Street: Fax:
City: State: Zip:    
   
Resale #:
Contact Name:
P. O. #:
Contact is: Acct. Payable / Manager / Owner
Display Stand: (Check all that apply)
 
4 Sider Swing Panels
4 Sider w/ Topper Wall Mounts
   
Assortments:
Reference 1:
Name: Phone:
Street: Fax:
City: State: Zip:    
   
Reference 2:
Name: Phone:
Street: Fax:
City: State: Zip:    
   
Reference 3:
Name: Phone:
Street: Fax:
City: State: Zip: