Customer Information Form

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Customer Information Form

Contact Information

* Indicates required field

Legal Company Name *

Contact Name *

First

Last

DBA *

Title / Position *

Phone Number *

Fax Number *

Email *

Billing Contact Information

Billing Contact *

First

Last

Billing Phone Number *

Type *

Fax Number *

Billing Email *

Billing Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Address *

Home Commercial

Shipping Contact Information

Shipping Contact *

First

Last

Shipping Phone Number *

Type *

Fax Number *

Shipping Email *

Shipping Address *

Line 1

Line 2

City

State

Zip Code

Country

Type of Address *

Home Commercial

Correspondence

Do you wish to receive tracking information via email? *

Yes No

Do you wish to receive invoices and statements via email? *

Yes No

Would you like us to contact you via email regarding new products and promotions? *

Yes No

Comment *

Attach Business License *

Max file size: 20MB

Attach Resale ID Exemption Form *

Max file size: 20MB

Submit

Keys Bit
940-663-5747
[email protected]

1696 FM 2568
Quanah, TX 79252

Home
About
Our Bits
Bit Repair
PDC Rental
Forms