Customer Info

Customer Info Sheet

Company Name

Point of Contact

Point of Contact

First

First

Last

Last

Billing Address

Billing Address

Billing Address

Billing Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Shipping Address (if different from Billing)

Shipping Address (if different from Billing)

Shipping Address (if different from Billing)

Shipping Address (if different from Billing)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Phone

Email

Website/URL

What sector do you primarily target?

What countries do you sell to?

Do you produce your own marketing materials?

What other products do you sell?

The undersigned, an owner, partner, or officer of the company named, hereby certifies that the information provided on this information is true and correct. The undersigned further agrees that this document is for information purposes only, and is not to be construed as an agreement assigning rights of agency or distributorship. Undersigned also confirms that LIFESAVING SYSTEMS CORP’s terms and conditions, as stated in LSC’s catalog and/or website are the only terms that shall to apply to all purchases from LSC.

Name of Signatory

Name of Signatory

Name

Name

Title/Position

Title/Position

Date

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