CUSTOMER INFORMATION SHEET

LEGAL NAME OF OWNER (S) OR CORP:

D/B/A IF DIFFERENT:

DELIVERY ADDRESS:

MAILING ADDRESS:

NAME OF MANAGER: PHONE:

EMAIL: FAX:

OWNER (S)/OFFICERS (S) NAME (S) AND HOME ADDRESS:

NAME & TITLE STREET ADDRESS CITY/STATE/ZIP PHONE

NAME OF BANK: ACCT. NO.:

BANK ADDRESS: PHONE:

NAME (S) OF PERSON (S) SIGNING CHECKS: (PLEASE PRINT)

DRIVERS LICENSE NO:

DRIVERS LICENSE NO:

SALES REP. I.D.

* DELIVERY INSTRUCTIONS:

* DELIVERY HOURS: