Patriot Industrial Products, Inc.

NEW CUSTOMER

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PROFILE INFORMATION

* First Name:

Title:

* Email Address:

* Password:

* Last Name:

* Phone:

Fax:

* Verify Password:

BILLING ADDRESS

* Company Name:

* Address 1:

Address 2:

* City:

* State:

* Zip:

* Country:

SHIPPING ADDRESS

Use Billing Information

* Company Name:

* Address 1:

Address 2:

* City:

* State:

* Zip:

* Country:

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Required fields are marked with an asterisk (*)

Profile Information

First Name

Last Name

Title

Phone

Email Address

Fax

Password

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Bill To Information
*	Company
*	Address1
	Address2
*	City
*	State
*	Zip
*	Country

Ship To Information		Use Billing Information
*	Company
*	Address1
	Address2
*	City
*	State
*	Zip
*	Country

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118-26 Colebrook River Rd
Winsted, Connecticut 06098
(860) 738-2446

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