Silver Dollar New Customer Registration Form

Customer Details:

Please enter the following information so we can add you to our system. Thank you!
Full Name of Primary Contact*

First NameLast Name
Business Name if Applicable
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is Shipping Address the same as Billing Address?

YesNo
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Secondary Phone Number If Applicable

Area CodePhone Number
Billing E-mail
Are you (or your company) tax exempt for agricultural, resale, or other reasons?

Agricultural useResale (please provide NTTC)Other (please explain below)No (tax rate is 6.0833%)
Explain tax exemption or provide NTTC #
How did you hear about us?

Please give reference of any two people whom you have done business within the last year:

	Full Name	Address	Contact Number
1
2

Customer Details: