Company Name:

Owner's Name:

Address:

City:

State:

ZIP:

Phone:

Fax: 

Email:

Taxable:
YES NO

If yes, a tax form will need to be completed.

EPA Certified:
YES NO

If yes, complete lower section.

Which of our locations will you be purchasing items from? (You may select more than one location.)
Mesquite Rockwall Lancaster Gun Barrel City Ft. Worth

The following are the names and certificate data for our employees who possess a valid EPA Refrigerant Certificate:

The following are the names of the persons authorized to pick up refrigerant, representing one or more of the certified technicians above:

Please fax, or mail a copy of each technician's certification card and driver's license for proper identification. This information is accurate as of (Date). Any change in the status of the above named certificate holders and additions or deletions to the list are the responsibility of the undersigned.

Please fill in your name and title:  

By submitting this form, you agree that this will serve as your electronic signature.
If you do not want to submit, you will need to fill out a form in person at one of our locations.