New shipping address

Customer account data

Existing account number * I do not know my account number

Customer name * Customer phone number *

New Shipping details (SHIP TO)

Name * Address1 * Phone

Existing Bill to

Existing bill to Same as Customer Account Data above Different as Customer Account Data above - please fill in below

Ordering information

EDI Capable * Yes No

EDI Contact Name * Invoice Delivery * By EDI By Email

Tracking Email Service * By EDI - 856 transaction By Emails By EDI and Email

Tracking Name of Recipient *

Important: If this form is not completed by the customer, written customer approval (email approval or purchase order) must be attached before the SHIP TO account can be created

Was this form completed by the customer? Yes - I am the customer No - I am submitting on behalf of the customer

Please confirm that the customer has authorized the creation of this SHIP TO account and that the information provided is accurate.

Submit