INTERNET SET-UP FORM FOR ONLINE ORDERING

Please complete this form and press SUBMIT FORM

 * Required Fields

                 Who is your Minton-Jones Sales Rep?

Account Number (If you know it):Dept. Number:

* Full Name:

*Organization:

*Department:

*Bill to Company Name:

*Bill to Street Address1:

*Bill To Street Address2:

*Bill to City:

*Bill to State:

*Bill to Zip Code:

*If different than Bill to Street Address1:

*If different than Bill to Street Address2:

City:

State:

Zip Code:

*Work Phone:

Fax:

*E-Mail:

Password Preference:

Order Approval Required:Yes  No 

Approvers Name:

Approver's E-mail:

IF YOU PLAN TO PAY BY P-CARD, PLEASE PROVIDE INFO BELOW.

Please provide Credit Card information if applicable: If you prefer to enter your Credit Card information at the time you place your order, just enter a note in the Additional Comments box below.

Name on Card:

CREDIT CARD TYPE:Visa  MasterCard  Amex  Discover 

Credit Card Number:Expiration: YYYY:MM:DD:

You may call your card information to Melinda Rugg at X115 if you prefer.

Additional Comments: