Business Info:

Business Name:
 
Required
Existing Customer:   New Customer:

Owner Name:
 

Your First Name:
 
Required

Your Last Name:
 
Required

Street Address:
 
Required

Unit/Suite/Apt#:
 

City:
 
Required

State or Province:
 

Zip/Postal Code:
 
Required

Country:
 
Required

Phone:
 
Required
Day:    Evening:    Mobile:

Email:
 
Required

Password:
Required
Choose a password to use to log into this site. Your email address will be your username. If you have already registered on our site, please type your existing password into this form.

Website:
 

Federal E.I.# (Tax ID):
 
Required
WI Dealers: If Tax Exempt and sending Form S-211, check here:

Please attach an electronic copy of your Seller’s Permit to this form. If you are unable to send it electronically, please mail a copy to us or fax it to (920) 893-4830.


How did you hear about us:
 
Required

Reference 1:
 

Years in business:
 

Reference 2
 

Years in business:
 

Reference 3
 

Years in business:
 

Additional Information

Please indicate your preferences for the following services:


Detonation/Welding Service:
 
Call before repairing
Fix and weld, no call required


Other requests to keep on file:
 

Preferred Shipping

Carrier:
 UPS    Fed-Ex

Delivery Time:
 Ground    Next Day Delivery    2-Day Delivery    3-Day Delivery

Shipping Address


Street Address:
 

Unit/Suite/Apt#:
 

City:
 

State:
 

Zip/Postal Code:
 

Payment

NOTE: If a form of payment is not indicated or a credit card number is not given, either on this form or over the phone, the work process could be delayed.

Payment Type:
 Credit Card    C.O.D

Billing Address


 Same as Shipping Address
 Different from Shipping Address:

Street Address:
 

Unit/Suite/Apt#:
 

City:
 

State:
 

Zip/Postal Code: