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!

Petro-Chemicals

There are no products that match your combination of options

Certifications

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