Primary Facility Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Contact *

First Name

Last Name

Phone *

(###)

###

####

Does this phone number accept Text Messages? *

YES

NO

Is Billing Address same as above? *

If Yes, please continue below. If No, please complete Billing Address information where all invoices and statements are to be delivered

YES

NO

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Accounts Payable Contact *

First Name

Last Name

Phone *

(###)

###

####

Preferred Billing Options *

Please indicate how you would like to receive your CSS Invoices and Account Statements

E-Mail

Fax

USPS Mail

Is Shipping Address same as Primary Address above? *

If Yes, please continue below. If No, please indicate where all return shipments are to be delivered

YES

NO

Delivery Address *

Please indicate the address location for all deliveries and return shipments

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Person *

Indicate the person responsible for receiving deliveries

First Name

Last Name

Recipient Contact Phone Number

Please indicate the best contact number for the delivery contact person.

(###)

###

####

Preferred Shipping Carrier *

Please indicate your preferred Shipping Carrier for all shipments/deliveries

Federal Express

UPS

Other

Secondary Shipping Carrier *

If applicable, please indicate your preferred secondary shipping carrier in the event your preferred carrier is not available.

Federal Express

UPS

OTHER

Shipment Option *

Please indicate how you would like your return shipments delivered:

Standard Overnight Service(Afternoon Delivery)

Priority Overnight Services(Morning Delivery)

2 Day Service

3 Day Service

Ground Service