Net Pricing Request

Submit one Net Pricing Request form per branch location.

Required fields are indicated with an asterisk ( * ) and must be completed before
your request can be accepted. Requests will be reviewed by your rep. When
verified, the Net Pricing will be sent to you via the method specified. Submission
of this form constitutes a single–event request and does not automatically generate
requests for any future price increases.

Electical Distributor Information

* Company

* Contact

Title

Address

Address (cont.)

* City

* State:

Zip:

* Branch LocationCity / State:

Account Number:

* Phone:

* Email

Mailing Information

Format

Email

CD (mail)

*
Email:

Terms and Conditions

This quotation is based on information supplied to Milbank
of which the validity is not known or confirmed. Therefore it is the customer's
responsibility to review the quotation for compliance and accuracy.

By submitting this request, I put forth that I am authorized by my company to
receive this Milbank proprietary information. I understand that this information
is the intellectual property of Milbank Manufacturing and is not to be distributed
outside of my company's authorized personnel.

I have read and agree with Milbank Manufacturing Company' s Net Pricing Terms and Conditions