Expediter - Request for Online Account

We are in the process of building an E-Commerce site. You will be able to enter your orders on-line, search products, and perform account inquiries. In order to set up your account for access to this helpful tool we need some information from you. The information you give us will only be used for this site, and no other purpose, it will not be passed on to any other party. The primary user will have supervisor rights on the site and will be able to add and delete new users for your company, and limit their access.

For each user we need:

a user ID
a password (at least 6 characters),
an e-mail address.

Please complete and submit the form below to aid us in preparing for E-Commerce.

Customer Code: (new customers leave blank)
Phone Number:
Business Name:
Primary Business: (trailer sales, hitches, utility, etc.)
Tax ID#:
NEW ACCOUNTS: Please complete so we may better assist with your online orders
Street Address:
City:
	State: Zip:
Shipping Address: (If different than mailing)
Shipping City:
	Shipping State: Shipping Zip:
Primary User's Online User ID:
Primary User's Name:
Primary User's Password:
Primary User's E-mail Address:

Please enter additional users you would like us to set up for you.

User ID:
User Password:
User's Name:
User's E-mail Address:

User ID:
User Password:
User's Name:
User's E-mail Address:

The information below is required in case we have any questions.

Person Completing Form: (Required)
Your Email: (Required)