ISO REQUIRED	NEW CUSTOMER FORM
	Please Complete All Fields
Date

Bill To Address:

Company Name:

Address:

City:

State:

Zip Code:

Country: 

Main Phone #:

Main Fax #:

Purchasing Contact:

E-mail Address:

Is a P.O. Required?

Yes

No

Send invoices: E-mail:

or

Fax #:

Certification Requirements:
Are certs required?	Yes	No	To Whom?

Send certs:

E-mail:

or

Fax #:

When:      Standard certification delivery is the day after shipment confirmation

---

Ship-to Address: (If different from above.) 

Company Name

(if different than Bill-To)

Address

City

State

Zip Code:

Phone #:	Fax #:
Warehouse Contact:	Warehouse Phone #:

Receiving Hours:     Yes      No

Is dock appointment required?

Yes No

Special Receiving Requirements (driver assist / no dock, etc)

Labeling Requirements:

PO#   Yes     No

Part#   Yes     No

Submit form or

FAX Form to:  847-849-5948   or E-mail to: credit@m-holland.com

M. Holland Company use ONLY

New Customer #: ____________________________ Ship-To #: ___________________ Abbreviation: ________________

   Entered by: __________________________________________               Date:  ___________________________________

Class Code: ____________________ End User Code: _____________________  Salesperson: ______________________

QF04-01

01/23/07