* Company name:    * Acct. #

* Phone number:   Fax number:

* Your E-Mail Address: 

List of locations where you frequently send deliveries:

* Company: 

* Street Address:

* Suite number: 

* City:   * State    * Zip:

* Phone number: 

 (with area code)

Company:  

Street address:

Suite number: 

City:    State Zip:  

Phone number 

(with area code) 

Company:        

Street address: 

Suite number:  

City:   State  Zip:

Phone number 

(with area code)