Company Information:

 Company Name:

 Shipping Manager:                                                       Area code & phone number

           Ext.

 Address:                            Bldg./Ste.   City:                                              Zip Code

 Shipping managers E-mail address:

 Billing Information:

 Same address as above:

 Attention To: (Accounts Receivable, i.e.)                         Area code & phone number

             Ext.

 Address:                            Bldg./Ste.   City:                                              Zip Code

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