INTERNET SET-UP FORM FOR ONLINE ORDERING

Please complete this form and press SUBMIT FORM

Check this boxto receive Promotional Flyers via e-mail and then complete the green highlighted boxes below.

Complete all Required Fields to be setup to order online.

                 Who is your Minton-Jones Sales Rep?

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

(Required) Full Name:

(Required) Organization:

(Required) Department:

(Required) Ship to Street Address1:

(Required) Ship to Street Address2:

City:

State:

Zip Code:

(Required) Work Phone:

Fax:

(Required) 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 

Last 8 digits of credit card:Expiration: YYYY:MM:DD:

Additional Comments: