Online Lead Form

Company Information

Company Name *

Sales Rep *

Phone *

Address Details

Billing Address *

Billing City *

Billing State *

Billing Zip *

Billing Country *

Check this Box if Billing and Shipping Info are the Same

Shipping Address

Shipping City

Shipping State

Shipping Zip

Shipping Country

Contact Information

Please provide the best contact information for the following:

Sales Contact (Order Confirmation/Order Fulfillment)

Name *

Title *

Phone *

Email Address *

Finance Contact (Invoices/Statements)

Name *

Title *

Phone *

Email Address *

Fulfillment Contact

Name *

Title *

Phone *

Email Address *

Marketing Contact (Print, Digital, Social Media Opportunities)

Name *

Title *

Phone *

Email Address *

Customer Center Setup

Give Access

Confirm Password *

Please Fill out the Additional Information

If you Choose Terms of Credit Card, the Billing Zip Code must match the Card on File

Requested Payment Terms *

Resale Certificate # *

Credit Authorization

Legal Entity Name *

Legal Entity Address *

Legal Entity City *

Legal Entity State *

Legal Entity Zip *

Legal Entity Country *

Tax ID # *

If you Selected Payment Terms of Net 30, we need to authorize a Credit Check

By typing your name in this box, you authorize COOLA to perform a credit check on your behalf. *

Credit Check Date of Authorization *

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Fill out the below if you have selected Payment Terms of Credit Card

By typing your name in this box, you are authorizing COOLA to keep a credit card on file, and charge all new invoices to the credit card provided *

CC Charge Date of Authorization *

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