Company Name *

Point of Contact Name *

First

Last

Point of Contact Email *

Point of Contact Phone *

Shipping Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Method of Shipping *

Forklift Onsite *

Loading Dock *

Liftgate Required *

Delivery Hours (M-F) *

Any Other Instructions

Customer Declaration *

Agree to Declaration

I/We hereby confirm that the information provided on this form is accurate, correct, and complete. Incorrect shipping details that result in additional shipping charges will be the responsibility of the client.