New Customer Account Setup

* required fields

Account type

New Account

* Company Name

* Ship to Address

* City

* State/Province

* Zip

-

For Placing Orders

* Contact Name

* Phone Number

( ) -

* E-mail Address

Accounts Payable and Billing

* Contact Name

* Phone Number

( ) -

* E-mail Address

Bill to Address (if different)

City

State/Province

Zip

-

* Products Sold & Serviced
(please check all that apply)

	Canon		Ricoh		Savin
	Gestetner		Lanier		Océ
	Konica/Minolta		Toshiba		Kyocera/Mita
	HP		Other:

Authorized Dealer Of

Dealer Code

* PO Number Required

Yes

No

*NWRS Invoice

Emailed to you

Included with order & packing slip

* How did you hear about NWRS?

Recommended By (if specified above)

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