Dispersion Technology Systems LLC

d.b.a. Electro-Fast Distribution
E-Mail: Accounting@electrofast.com
Phone: 610-279-8294 x106 for A/R and x100 for Customer Service
Fax: 610-279-3917

ETF Customer ID to be used: (Salesrep#+Name to be used)

Registered Company Name

D.B.A.

Phone for ordering

Fax

Number is not required

Website

Billing Information

A/P Contact Name

A/P phone

E-Mail for Invoices

E-Mail for Statements

Enter only if different than above

Billing Street

Billing City

Billing State

Billing Code

Zip Code+4

Ordering & Shipping Information

First Name

Last Name

Phone

Email

Attention

Include Name or Location here for shipping, if needed

Shipping Street

Shipping City

Shipping State

Shipping Zip+4

Shipping County

Used for local taxes

PO Required

Select option, default is YES

B/O allowed

Select option, default is YES

Perferred Shipping Method

Select shipping carrier, default is UPS

Shipping Code

Add your UPS or FedEx shippers ID here, if so desired.

Tax Exempt Number?

If tax exempt, E-mail tax exemption form to: accounting@electrofast.com