New Customer

Account Information

Company Name*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Shipping Address (if different from Billing Address)

Street Address Address Line 2 City State ZIP Code

Lift Gate Required for shipments?*

Yes
No

Phone*

Website*

Enter "none" if you do not have a website.

Contractor's License #*

Number of Trucks

How did you hear about us?*

If employee, please provide name of Employee and Previous Company:*

Other:*

Contact Information

Primary Contact*

First Last

Phone*

Email*

Warehouse/ Shipping Contact

First Last

Phone

Email

Plumbing Manager

First Last

Phone

Email

Marketing Contact

First Last

Email

Phone

Send Invoices to:*

First Last

Email*

Primary contact for orders:*

Email, if not already provided

Membership Information

Nexstar Member?

Yes

Nexstar Member #

PHCC Member?

Yes

PHCC Member #

Praxis Member?

Yes

Praxis Member #

New Dealer Registration

Account Information

Contact Information

Membership Information