New Customer - Griffin Heat Shield

Use this form to sign up to begin selling Griffin Heat Shield products in your store.

Company Name
Shipping Address
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Billing Information
- Same as Shipping
- Different
Billing Address
Street Address Address Line 2 City State ZIP Code
Billing Phone
Billing Fax
Accounts Payable Contact*
First Last
Email*
Phone*
Fax
Requested Payment Terms
Please select one
- Net 30
- Credit Card
Invoices emailed to:
Is there a UPS shipping account number you would like for us to use?
Zip
Trade References
Use the + sign to add more.
Company Name Phone
What is your type of business?
- Retail Supply Store
- End User
Terms*
I/We certify that the above information is true and correct. I/We agree to pay this account in accordance with the credit terms established above.

Company Name	Phone