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[ Vinimark Trading: On line order registration ]
* Indicates a required field
Vinimark Customer Code / Login
* (Your existing Vinimark account number)
Password
*
Verify Password
*
Customer Trading Name
*
Customer Legal Name
Contact person for orders
Name
*
Surname
E-mail address for order confirmations
*
Confirm E-mail address for order confirmations
*
Contact No. (Work)
Contact No. (Cell)
Contact No. (Fax)
Would you like to receive product updates and marketing information from us?
*
Yes
No
Contact person for accounts
Same as Orders Contact
Name
*
Surname
E-mail address
*
Confirm E-mail address
*
Contact No. (Work)
Contact No. (Cell)
Contact No. (Fax)
Would you like to receive product updates and marketing information from us?
*
Yes
No
Yes/No
Authorized Applicant
Same as Orders Contact
(Person authorized to register for on line orders)
Name
*
Surname
*
Contact No. (Cell)
*
On line orders: Terms and Conditions
I acknowledge that I have read and agree to the
Supplemental terms of use
Agree
Submit