HSLdirect Customer
Registration Form
To register, please complete this form and fax to Hydromat at: 314.432.4458
Company Information
Company Name:
Address:
City:
State:
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Country:
Postal Code:
Phone:
Fax:
Individual Information
Name:
Title:
Phone:
Fax:
e-mail:
Please provide your own individual company e-mail address.
Shared e-mail addresses cannot be processed.
Applicant's Signature:
Executive Authorization
Name:
Phone:
Fax:
Signature:
Print form. Must have executive signature, i.e. Plant Manager, Purchasing Manager, President.
Fax to Hydromat at 314.432.4458
Please use this print button to accurately print the form.
For Internal Purposes Only
Customer Account No.:
Approval: