Customer Info Required to Create FAP account

Please print out and fill in this form and fax it in with the software agreement.
Optimus fax numbers 901-794-3884 or 901-259-1175

Customer Name:

____________________________

Customer Account No:

____________________________

Customer Contact:

____________________________

Customer Phone No:

____________________________

E-mail address:

____________________________

Default Ship2:

____________________________

 Shopping Cart Enabled:

     Yes                No

Special Customer Pricing:

     Yes                No