Corporate Account Information

Please fill in the form below to create an account with American Material Handling Corporation. Required fields are marked with an asterisk (*). When the form is complete, click the Submit Application button.

GENERAL INFORMATION

Company Name:	*
Years in Business:	*

PRIMARY CONTACT
First Name:	*
Last Name:	*
Phone Number:	() - *

SECONDARY CONTACT
First Name:
Last Name:
Phone Number:	() -

LOGIN INFORMATION
Email:	*
Username:	* (6-15 Characters)
Password:	* (6-15 Characters)
Confirm Password:	*

SHIPPING INFORMATION

First Name:	*
Last Name:	*
Address 1:	*
Address 2:
City:	*
State:	*
Province:
Zip Code:	*
Country:	*
Phone Number:	() - * ext.
Alt Phone Number:	() - ext.

BILLING INFORMATION

Check this if billing address is the same as your shipping address

First Name:	*
Last Name:	*
Address 1:	*
Address 2:
City:	*
State:	*
Province:
Zip Code:	*
Country:	*
Phone Number:	() - * ext.
Alt Phone Number:	() - ext.

PAYMENT INFORMATION

Please note Bank references are not required for Credit Card Applications
Pay by Credit Card Pay by PO Number

Payment Type:
Card Number:
Name on Card:
Card Expiration:
Security Code:	Click here to find code

Tax ID:
Dunn Number:

BANK REFERENCE
Bank Name:
Bank Number:


CREDIT REFERENCE 1:
Name:
Address 1:
Address 2:
City:
State:
Postal Code:
Phone:	() -
Email:

CREDIT REFERENCE 2:
Name:
Address 1:
Address 2:
City:
State:
Postal Code:
Phone:	() -
Email:

CREDIT REFERENCE 3:
Name:
Address 1:
Address 2:
City:
State:
Postal Code:
Phone:	() -
Email: