Billing Attention Name * Name of Company Billing Attention E-Mail * Billing Phone Address * City * State * Zip * Order Contact Name (Leave Blank if Same as Above) Order Contact E-Mail (Leave Blank if Same as Above) Order Phone (Leave Blank If Same as Above) Taxable? * Choose One: Yes No Tax Exempt? * Choose One: Yes No *If yes, please provide copy of certification. Number of Employee's * Current Vendor * Multiple Locations? Choose one: Yes No How Many Locations? Add Info for Other Locations Sales Rep at Great River? How Did You Hear About Great River? Comments