Customer Setup Form

We keep the information provided on this form in our files for contact, shipping, and accounting purposes.

Business Legal Name (As Seen on W9) *

Primary Contact *

Phone *

Cell

Email *

Registered in Which State *

Est. Monthly Purchase

Type of Business *

Sole Prorietorship
Partnership
LLC
Corporation

Tax Exempt *

State Tax Exemption Form *

Billing Contact *

Billing Phone *

Billing Email *

Billing Address *

City *

State *

Zip *

Shipping Contact, Phone, Email *

Same As Primary
Same As Billing
Different

Shipping Contact Name *

Shipping Phone *

Shipping Email *

Shipping Info Same As Billing Address *

Shipping Address *

City *

State *

Zip *

Multiple Ship-To's *

List Additional Ship-To's Information *

Choose All That Apply *

CO2
Dry Ice
Other Gasses
Filter Media
Undenatured Ethanol
Heptane, Hexane, or Pentane
CDA-12A
Carrier Oils
Industrial Chemicals

Checkbox

Option 1
Option 2

I Understand I am required to complete an Ethanol End-User Form and upload of my Driver License or U.S. Passport before any orders of Undenatured 190 or 200 Proof Ethanol can be shipped. *

Receiving Hours *

Is Receiving Closed For Lunch *

Lunch Hours *

Does Your Receiving Dept Require an Appointment for Deliveries *

Receiving Manager Name *

Receiving Manager Phone *

Are You Planning to Order: Check All That Apply *

Drums
Totes
Tankers

Forklift on Site *

Life Gate Required for Deliveries *

Dock on Site *

Stationary Holding Tank On Site *

Stationary Holding Tank Capacity (gallons) *

Connection Size on Stationary Tank (i.e: 2" or 3", male or female came lock) *

Does Tank Require a Pump *

Hose Length Required to Reach tank from Delivery Truck Parking Area *

Do Deliveries Require a Weight Ticket *

Is Nitrogen or Compressed Air Available on Site *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

All Your Gases in One Place

Packaging To Fit Your Business

Tankers Available for Limited Products

Gases

Ethanol

Denatured Ethanol

Solvents

Certifications

Many of our products carry one or more of the following certifications