Please complete and submit the form below. Our Customer Service department will contact you for additional information if necessary. Or, you may print out this form and fax it to (508)842-4406. Name: Title: Company Name: Mailing Address: Shipping Address: City: State/Province: Country: Zip: Email: Work Phone: Fax: Company Website: Comments:       Type of Industry Injection Molding   Blow Molding     Extrusion   Semiconductor      Tool Maker         Chemical Pharmaceutical     Medical & Food Other Would you like to have a representative contact you? yes   no Would you like to receive our e-mail Newsletter? yes   no Would you like to receive information on new products and special promotions? yes   no To remove your name from our email list, please send your request to customerservice@plastixs.com Would you like to set-up a direct billing account with us? yes   no