USA Decommissioning New Customer Information Request Form

Phone

This field is for validation purposes and should be left unchanged.

Customer Business Name*

Customer Contact/Representative Name*

First Last

Customer Email*

Customer Office Phone*

Customer Cell Phone

Customer Website

Customer HQ Address*

Street Address Suite/PO Box/Building City State ZIP Code

Customer Accounting Department Address*

Same as previous

Street Address Suite/PO Box/Building City State ZIP Code

Accounts Payable Contact

Leave blank if there’s no specific A/P contact person

First Last

Accounts Payable Email Address*

Accounts Payable Phone

Reselling equipment purchased from USA Decom?

We require all resellers buying products from Illinois, Oklahoma and Texas to submit a resale certificate.

Upload Resale Certificate

Max. file size: 256 MB.