DAC IndustriesNew Customer Information

New Customer

URL

This field is for validation purposes and should be left unchanged.

Bill To / Ship To

Billing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Address(Required)

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contacts

Accounts Payable / Recievable Contact(Required)

First Last

Position Title(Required)

Phone(Required)

Extension

Email(Required)

Purchasing contact is same as above(Required)

Yes

No

Purchasing Contact(Required)

First Last

Position Title(Required)

Phone(Required)

Extension(Required)

Email(Required)

Do you know who will be using / managing the department where our products will be used?(Required)

Yes

No

End User Contact(Required)

First Last

The person who will be using our products, or the manager of the department where our products will be used.

Title / Position(Required)

Phone(Required)

Email(Required)

Shipping Information

Will you be using your shipping account?(Required)

Yes

No

If you do not use a collect account, DAC will ship via ground with the lowest-cost carrier at the time of order.

Carrier(Required)

UPS

FedEx

Spee Dee

Freight / Other

Company(Required)

Account Number(Required)

Authorization

By signing below, you are acknowledging and accepting DAC Industries’ payment terms of net 30 days. Invoices not paid within the Net 30 days are subject to an interest charge of 1% per month beginning 30 days after the date of invoice.

Authorizing Representative(Required)

First Last

Employee authorized to submit this request on behalf of the company

Signature(Required)

Date(Required)

Cart

New Customer

Company Information

Bill To / Ship To

Contacts

Shipping Information

Authorization