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Customer Profile Form
In an effort to keep our Customer database records up-to-date with your latest Company and Contact information, we are requesting a few moments of your time to assist us by completing the Customer Profile Form.
If your Company’s End-User, Product Shipping and Invoicing Information is the same, then please complete SECTION A only; otherwise, please complete all sections in full.
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Customer / End-User Information: Section A
Company Name:
Contact Name:
Company Email Address:
Company Phone #:
Company Fax #:
Address:
City/Town:
Province/State:
Choose a Province or State Outside U.S. & Canada Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada Newfoundland/Labrador New Brunswick New Hampshire New Jersey New Mexico New York North Carolina North Dakota Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon Territories
Zip/Postal Code:
Company URL/Web Site:
Product Shipping Information: Section B
Shipping Contact:
Shipping Contact Email Address:
Shipping Contact Phone #:
Shipping Contact Fax #:
Shipping Address:
Invoicing Information: Section C
Invoicing Contact:
Invoicing Contact Email Address:
Invoicing Contact Phone #:
Invoicing Contact Fax #:
Invoicing Address:
By keeping our customer database records up-to-date with the latest information, we will be better able to assist you with timely customer support, distribution of Marketing information.
THANK YOU, once again!