New MLH Customer Application

  • Please complete all fields as incomplete forms will delay new account set up.
  • We will contact you via e-mail with your new account # as soon as possible after receiving your completed form. Please make a note of your account # for faster order processing.
  • If you prefer, you can print out the application and submit completed form online to customersupport@pipetman.com or print and fax form to 608-821-4403.
Salutation: Please note: When filling out company name, first name or last name, please do not use any periods (.), commas (,) or any other punctuation marks.
Job Function:  
Company:  
First Name:   Last Name:  
Email:    
Phone Number:     Fax Number:    

Billing Address
Address 1:   Please note: When filling out billing, shipping and mailing address information, please do not use any periods (.), commas (,) or any other punctuation marks.
Address 2:
Address 3:
   
City 		   
State 		   
Zip Code
A/P Contact Name: Email:
Phone Number: Fax Number:

Shipping Address  
Address 1:  
Address 2:
Address 3:
   
City 		   
State 		   
Zip Code

Mailing Address     
Address 1:  
Address 2:
Address 3:
   
City 		 
State 		 
Zip Code
Market Segment:
Payment Preference: * Hard copy PO is required for first order.
PO # Format:
Reseller:
Are your purchases: * Please fax copy of exemption certificate to 608-831-4451, ATTN: Accounting
Preferred Shipper*: * Gilson default shipper is UPS for best shipping rate.
Collect Account #*: * Gilson will 'prepay & add' if collect account # is not provided.
 
Please Note: All sales are Net 30 days, FOB, Middleton, Wisconsin. Freight charges are prepaid and added to your invoice unless a collect account number is provided.

Would you like to receive discount offers and promotional materials from Gilson?
 
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