ESSENTIAL CUSTOMER INFO

Essential information to create your account profile
In effort to equip us with the information about your organization's expectations for on-time delivery and any unique marking/packaging requirements we ask that you complete this form as it may apply.
Company name*
Phone*
Email*
example@example.com
Bill To
Address*
City*
State*
Zip code*
Ship To
Address*
City*
State*
Zip code*
Phone Number at this location*
Receiving Info
Receiving hours*
Receiving contact*
Receiving Phone Number*
Are appointments required? (Yes or No)*
Contact info*
Are your part numbers required on the containers we ship? (Yes or No)*
If yes, please sent the list of numbers and associated product names to compliance@aglayne.com
Our orders are for*

DeliveryWill Call
NOTE: Will Call customers must supply us with a certificate of insurance showing current workers compensation coverage.
Please list your holiday closures and/or reduced hours below*
Should be Empty:

Essential information to create your account profile