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Submitted URL: https://email.lango.co/e3t/Ctc/UB+113/d2qJzY04/VVLgrc68SHFdW3-wrqP7Z9NgPW9ccHTJ5bzWv3N6pj1WP3lYMRW6N1vHY6lZ3mpVHY7Mq8-w...
Effective URL: https://share.hsforms.com/1jh8F6teBRjCnDukglqBysQc93je?utm_medium=email&_hsmi=296487810&_hsenc=p2ANqtz-_4cN0itUhn3ZB0DGwfs...
Submission: On March 13 via manual from US — Scanned from DE
Effective URL: https://share.hsforms.com/1jh8F6teBRjCnDukglqBysQc93je?utm_medium=email&_hsmi=296487810&_hsenc=p2ANqtz-_4cN0itUhn3ZB0DGwfs...
Submission: On March 13 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="hs-form-8e1f05ea-d781-4630-a70e-e92096a072b1-ee2a73bb-7f80-4db0-b230-b9ed7b93d2eb" class="hs-form-8e1f05ea-d781-4630-a70e-e92096a072b1 hs-form hs-form_theme-canvas" data-instance-id="ee2a73bb-7f80-4db0-b230-b9ed7b93d2eb"
data-form-id="8e1f05ea-d781-4630-a70e-e92096a072b1" data-portal-id="20579882" lang="en" data-test-id="hs-form-8e1f05ea-d781-4630-a70e-e92096a072b1-ee2a73bb-7f80-4db0-b230-b9ed7b93d2eb" data-hs-cf-bound="true">
<div class="hs-form__pagination-content-container">
<div class="hs-form__row">
<div class="hs-form__group">
<div data-hsfc-id="RichText" style="font-size: 14px; color: rgb(51, 71, 91);">
<h1>Customer Registration Form</h1>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-firstname hs-firstname"><label id="firstname-label" for="firstname-input" class="hs-form__field__label" data-required="true"><span lang="en">First name</span><span
class="hs-form__field__label__required">*</span></label><input id="firstname-input" class="hs-form__field__input" type="text" name="firstname" required="" autocomplete="given-name" inputmode="text" aria-invalid="false"
aria-required="true" value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-lastname hs-lastname"><label id="lastname-label" for="lastname-input" class="hs-form__field__label" data-required="true"><span lang="en">Last name</span><span
class="hs-form__field__label__required">*</span></label><input id="lastname-input" class="hs-form__field__input" type="text" name="lastname" required="" autocomplete="family-name" inputmode="text" aria-invalid="false"
aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-company hs-company"><label id="company-label" for="company-input" class="hs-form__field__label" data-required="true"><span lang="en">Name of Organization as Shown on W-9. If you're not an
organization, please add your name.</span><span class="hs-form__field__label__required">*</span></label><input id="company-input" class="hs-form__field__input" type="text" name="company" required="" autocomplete="organization"
inputmode="text" aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-address hs-address"><label id="address-label" for="address-input" class="hs-form__field__label" data-required="true"><span lang="en">Street address</span><span
class="hs-form__field__label__required">*</span></label><input id="address-input" class="hs-form__field__input" type="text" name="address" required="" autocomplete="address-line1" inputmode="text" aria-invalid="false"
aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-city hs-city"><label id="city-label" for="city-input" class="hs-form__field__label" data-required="false"><span lang="en">City</span></label><input id="city-input" class="hs-form__field__input"
type="text" name="city" autocomplete="address-level2" inputmode="text" aria-invalid="false" value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-state hs-state"><label id="state-label" for="state-input" class="hs-form__field__label" data-required="false"><span lang="en">State/Region</span></label><input id="state-input"
class="hs-form__field__input" type="text" name="state" autocomplete="address-level1" inputmode="text" aria-invalid="false" value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-zip hs-zip"><label id="zip-label" for="zip-input" class="hs-form__field__label" data-required="true"><span lang="en">Postal code</span><span
class="hs-form__field__label__required">*</span></label><input id="zip-input" class="hs-form__field__input" type="text" name="zip" required="" autocomplete="postal-code" inputmode="text" aria-invalid="false" aria-required="true"
value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-email hs-email"><label id="email-label" for="email-input" class="hs-form__field__label" data-required="true"><span lang="en">Email</span><span
class="hs-form__field__label__required">*</span></label><input id="email-input" class="hs-form__field__input" type="email" name="email" required="" autocomplete="email" inputmode="email" aria-invalid="false" aria-required="true"
value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-phone hs-phone"><label id="phone-label" for="phone-input" class="hs-form__field__label" data-required="false"><span lang="en">Phone number</span></label>
<div class="hs-form__field__phone"><input id="phone-input" class="hs-form__field__input" type="tel" name="phone" autocomplete="tel" inputmode="tel" aria-invalid="false" value=""></div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_contact_name hs-billing_contact_name"><label id="billing_contact_name-label" for="billing_contact_name-input" class="hs-form__field__label" data-required="true"><span lang="en">Billing
Contact Name</span><span class="hs-form__field__label__required">*</span></label><input id="billing_contact_name-input" class="hs-form__field__input" type="text" name="billing_contact_name" required="" inputmode="text"
aria-invalid="false" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_address hs-billing_address"><label id="billing_address-label" for="billing_address-input" class="hs-form__field__label" data-required="false"><span lang="en">Billing
Address</span></label><input id="billing_address-input" class="hs-form__field__input" type="text" name="billing_address" inputmode="text" aria-invalid="false" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_city hs-billing_city"><label id="billing_city-label" for="billing_city-input" class="hs-form__field__label" data-required="false"><span lang="en">Billing City</span></label><input
id="billing_city-input" class="hs-form__field__input" type="text" name="billing_city" inputmode="text" aria-invalid="false" value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_state hs-billing_state"><label id="billing_state-label" for="billing_state-input" class="hs-form__field__label" data-required="false"><span lang="en">Billing State</span></label><input
id="billing_state-input" class="hs-form__field__input" type="text" name="billing_state" inputmode="text" aria-invalid="false" value=""></div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_postal_code hs-billing_postal_code"><label id="billing_postal_code-label" for="billing_postal_code-input" class="hs-form__field__label" data-required="true"><span lang="en">Billing Postal
Code</span><span class="hs-form__field__label__required">*</span></label><input id="billing_postal_code-input" class="hs-form__field__input" type="text" name="billing_postal_code" required="" inputmode="text" aria-invalid="false"
aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-billing_email hs-billing_email"><label id="billing_email-label" for="billing_email-input" class="hs-form__field__label" data-required="true"><span lang="en">Billing Email</span><span
class="hs-form__field__label__required">*</span></label><input id="billing_email-input" class="hs-form__field__input" type="text" name="billing_email" required="" inputmode="text" aria-invalid="false" aria-required="true" value="">
</div>
</div>
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-branch_phone hs-branch_phone"><label id="branch_phone-label" for="branch_phone-input" class="hs-form__field__label" data-required="true"><span lang="en">Billing Phone</span><span
class="hs-form__field__label__required">*</span></label><input id="branch_phone-input" class="hs-form__field__input" type="text" name="branch_phone" required="" inputmode="text" aria-invalid="false" aria-required="true" value="">
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-tax_exempt_ hs-tax_exempt_">
<div id="tax_exempt_-label" class="hs-form__field__label" data-required="true"><span lang="en">Tax Exempt? (If Yes, please send Tax Exempt Certificate)</span><span class="hs-form__field__label__required">*</span></div>
<div style="display: flex; flex-grow: 1; align-items: flex-start; justify-content: flex-start; flex-direction: row;">
<div class="hs-form__field__options__container" role="radiogroup" aria-invalid="false" aria-required="true" aria-labelledby="tax_exempt_-label">
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="tax_exempt_-label-1" class="hs-form__field__label hs-form__field__radio__label"><input id="tax_exempt_-input-1"
class="hs-form__field__input hs-form__field__radio__input" type="radio" name="tax_exempt_" aria-invalid="false" aria-labelledby="tax_exempt_-label-1" value="Yes"><span
class="hs-form__field__radio__label-text">Yes</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="tax_exempt_-label-2" class="hs-form__field__label hs-form__field__radio__label"><input id="tax_exempt_-input-2"
class="hs-form__field__input hs-form__field__radio__input" type="radio" name="tax_exempt_" aria-invalid="false" aria-labelledby="tax_exempt_-label-2" value="No"><span class="hs-form__field__radio__label-text">No</span></label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-confirmation___approval hs-confirmation___approval"><label id="confirmation___approval-label-1" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="confirmation___approval-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="confirmation___approval" aria-invalid="false" aria-required="true"
aria-labelledby="confirmation___approval-label-1" value=""><span class="hs-form__field__checkbox__label-text">Confirmation & Approval: By checking this box I consent that all of the information above is accurate and that I have
the authority to submit this information.</span><span class="hs-form__field__label__required">*</span></label></div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__actions"><button type="submit" name="Submit" class="hs-form__actions__submit" lang="en">Submit</button></div>
</div>
<div id="ee2a73bb-7f80-4db0-b230-b9ed7b93d2eb-live-region-content" class="hs-form__visually-hidden" aria-live="polite"></div>
</form>Text Content
Skip to form CUSTOMER REGISTRATION FORM First name* Last name* Name of Organization as Shown on W-9. If you're not an organization, please add your name.* Street address* City State/Region Postal code* Email* Phone number Billing Contact Name* Billing Address Billing City Billing State Billing Postal Code* Billing Email* Billing Phone* Tax Exempt? (If Yes, please send Tax Exempt Certificate)* Yes No Confirmation & Approval: By checking this box I consent that all of the information above is accurate and that I have the authority to submit this information.* Submit