Parent Company: YES NO  
Company Name: Ship To:
Attention Attention
Address Address
Phone # () -  
Fax # () -  
Owner's Name  
Driver's License # Bill To:
Birth Date - - Attention
Social Security # - - Address
Federal ID # Phone # () -
Resale Tax # (Note: Without sales tax number you will be automatically charged tax where applicable.) Fax # () -
Accounts Payable Contact:  
Taxable YES NO
. 		Have you or an affiliate done business with us in the past? YES NO
.
Backorder Accepted YES NO
. 		If Yes, Name of Location or Customer #
PO Number Required YES NO
. 		   

Comments/Special Requests:

Due to the importance of all your information,
please print this form,
once it is properly filled out,
fax or
copy and paste and email to us
for prompt response.
1-305-225-4821
Allow 3-5 business days to process.
You will be notified as soon as it is processed.

 

Eclipse Ent. Int'l, Inc.

P.O.Box 654007  Miami, Florida  33265-4007 USA
Phone:(305) 554-1181   Fax:(305) 225-4821

E-Mail : form@eeii.com