Change your Bill

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370 State St. ● Salem, OR 97301 ● Phone: 1-503-581-1404 ● Fax: 1-503-588-0949

Your

Please fill the following form out completely to instantly activate your new account.

You can also call us at 503-581-1404 for assistance in setting up your new account.

My Log-In Information
Login Name:	(10 char. max)	P.O. Number:
Password:	(10 char. max)	Department:
Password:	(10 char. max)	Comment:
Contact Name:
*Telephone:**
Fax :
*E-Mail :**
Bill-To Information		Ship-To Information Same as Bill-To Information
Company Name:
Address 1:
Address 2:
*City:**
*State:**
*Postal Code:**