/PAY WITH CREDIT CARD Already a Werner Customer and Need an Online Account? SIGN UP NOW Company Name*Billing Address* Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Address Street Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is your preferred pick up location?*Cottage GroveDuluthEau ClaireLa CrosseMankatoOwatonnaSt. CloudRochesterSales Tax Exempt*Yes, if exempt will need copy of signed sales tax certificateNoType of Business?*What best describes your work?*IndustrialContractorMonthly Statement Required*YesNoA/P Contact*Email Are you the online ordering admin? This Role sets up and maintains user accounts for your company?*YesNoIf No, Who would be the Online Order Admin for your Company?*Admin Job Title*Email* Phone*Full Name*Job Title*Email Address* Phone*Terms & ConditionsCustomer consents to the release of credit reference or credit information at any time by any party listed as a Credit or Bank Reference. Customer agrees to pay Werner Electric’s actual attorneys’ fees in the event delinquent account balances are referred to an attorney for collection. This agreement and any actions between the parties to this agreement shall be governed in Washington County, MN, and the parties agree that this is an appropriate venue as Werner Electric is located in Washington County and this agreement shall be deemed entered into in Washington County, MN. Terms are credit card only; past-due balances bear interest at the rate of 1.5% per month. The undersigned warrants the accuracy of the above information and agrees to the terms set forth above.E-Signature*Untitled*
