                                                                                
                                  CLIENT FORM                                   
                                                                                
                                                                                
   Last Name _______________       First Name ___________     Title _______     
                                   Spouse     ___________                       
                                                                                
                                                                                
   Company Name    _____________________________     Company Id # _________     
   Street address  _____________________________                                
   City / State    _____________________________     ZIP _______                
                                                                                
                                                                                
   Home phone        (___) ___-____-____          Total purchases _________     
   Work phone        (___) ___-____-____          Credit Terms    _________     
   last contact date  ________                    Credit Rating   _             
                                                                                
                                                                                
   Mailing times   weekly __   bi-weekly __   monthly __    bi-monthly __       
                                                                                
                                                                                
                                 Comments                                       
     ____________________________________________________________________       
     ____________________________________________________________________       
     ____________________________________________________________________       
                                                                                
                               Post Script                                      
     ____________________________________________________________________       

	
	E//C:C
CC % %*7H			
DDDD	

	



	







































ZIP       W. PHONE4 W. PHONE3 W. PHONE2 W. PHONE1 TOT PURCH.TITLE     STREET AD.
SPOUSE    LAST NAME L CONTACT H. PHONE4 H. PHONE3 H. PHONE2 H PHONE1  FIRST NAME
CR. TERMS CR. RATINGCOMPANY IDCOMPANY   CITY/STATEH. PHONE2 H PHONE1  FIRST NAME
