New Customer Information Form

Become a new customer...

This form is to help identify what type of service you require and a qualified sales representative will e-mail or call you after submitting this information.
Note: we are not permitted to ship major label items outside the U.S. borders.

Type of Customer:

Home or Single Jukebox
Jukebox Operator
Retail Store
College Bookstore
Mass Merchant
Public Library

Interested in purchasing:

CD
DVD
LP
12" Vinyl
45's
Accessories
Latin CD's
Latin 45's
Other

Please provide the following contact information:

Your Name

Organization

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Phone

FAX

E-mail

Please provide a password:

Password

Confirm Password

(For use with online ordering)

Choose one of the following payment options:

You will be mailed or faxed credit card form or credit application by a sales representative depending on your selection.

Credit Card
COD Cash
COD Check
Terms
(If you select 'Credit Card' we will contact you via phone to get the required information)

Any special notes or requests?

Do you want us to keep any backorders on file until you place your next order?

Yes No

11012 Aurora Hudson Road Streetsboro, OH 44241
Phone: (330) 528-0410

New Customer Information Form

Become a new customer...

This form is to help identify what type of service you require and a qualified sales representative will e-mail or call you after submitting this information. ** Note: we are not permitted to ship major label items outside the U.S. borders. **

This form is to help identify what type of service you require and a qualified sales representative will e-mail or call you after submitting this information.
Note: we are not permitted to ship major label items outside the U.S. borders.