NEW CUSTOMER FORM

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Company Name*

AUTHORIZED REPRESENTATIVE

Name*

First Last

Email*

Phone*

ADDRESS

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Shipping Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Shipping Address Different than Billing Address?*

Do you have a second Shipping Address?*

Do you have a Third Shipping Address?*

Shipping Address Two*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Shipping Address Three*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

SHIPPING INSTRUCTIONS

Shipping Address Type*

Truck Load Capable*

Liftgate Required*

SIGNATURE

Typed Signature Declaration: I hereby declare that my typed signature appearing below is my legal and binding signature, and I intend it to have the same force and effect as a handwritten signature. By typing my name, I affirm that I am the intended signatory and that I acknowledge and agree to the terms and conditions set forth in this document.

Signature*

Title*

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NEW CUSTOMER FORM

AUTHORIZED REPRESENTATIVE

ADDRESS

SHIPPING INSTRUCTIONS

COMPANY INFORMATION

SIGNATURE

BAGS

BOXES

TISSUE

RIBBON

CUSTOMIZE

SHOWCASE

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3 Opportunity Way, Newburyport, MA 01950 1.800.722.7732

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