Goodyear Rubber Products
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ACCOUNT DETAILS ACCOUNT DETAILS Fax back to: ACCOUNT INFORMATION Fax back to: REQUEST FORM Your Account number is: _______________________ Your Mulitplier is:____________________ Your Outside Sales Representative:__________________________________________________ Sales Representative Contact Information:___________________________________________ Account Manager Online Ordering � View / Modify Account Settings Manage Part Number's � Download Pricing Your Customer ID:____________________________________________ SAVE Your Authorization Code is: ___________________________________ 5% ------------------------------------------ Fill out the following beforeing------------------------------------- Order Confirmations � Invoices � Statements We are only sending Order Confirmations, Invoices and Statements by either or e-mail. Which would you prefer? Fax e-mail None Order Confirmation (Fax# or e-mail):______________________________ Invoices (Fax# or e-mail): ________________________________________ Statements (Fax# or e-mail):______________________________________ Monthly E-Newsletter (New Products and Promotions at Midland) ! Yes, Sign me up e-mail address:_______________________________________________ LITERATURE ORDER FORM Please send me: !-Additional copies of the new Aug 2006 Catalog QTY______ !-Copies of the Generic "no name" catalog at $3.00 each QTY______(see generic catalog page) !-2006 Catalog on CD QTY______ !-A Midland Metal Binder to keep my current Midland Literature in. Please send to : Account # or Company Name:________________________________ Contact Name: _____________________ Address:_______________________________________#___________________________ City: __________________________________________ State: ______________Zip: __________ Special Notes: _____________________________________________________________________ IDLAND ETAL FG. CO. Intro I
Goodyear Rubber Products
