Customer Information Form Today's Date: Company Name: Phone: Mailing Address: City: State: Zip Code: Accounts Payable Contact Contact Name: Contact Phone: Contact Email: Preferred Payment Method: ACH (Preferred) Credit Card Check How do you prefer to receive invoice copies? Email US Mail Fax Exempt from Sales Tax? No Yes (ST Exemption Form Required) Purchasing Contact Contact Name: Contact Phone: Contact Email: Ship Address: Attention (Attn): Preferred Shipping Method: Bestway Other (Specify Below) Product Information Which brand are you interested in? Diamondback Perkins Rotac Qwik Tip Systems What style loader are you outfitting? Rear Load Side Load Specialty What truck are you outfitting? Do you need help identifying your cart tipper or part? Yes No Upload an Image (Optional - Cart Tipper or Part Identification): How did you hear about us? Magazine Ad Google Word of Mouth Facebook YouTube Other (Specify Below)
