New Customer Information Please enable JavaScript in your browser to complete this form.Name *FirstLastCompany *Business Name (Public Name) *Describe your business *Email *Phone *Billing Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRepeat AddressShipping Address same as Billing AddressShipping AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBank Transfer or Debit/Credit Card Payment AuthorizationYou authorize regularly charges to your bank account or debit/credit card. A receipt for each payment will be provided to you and the charge will appear on your bank account or debit/credit card statement. You agree that no prior notification will be provided unless the terms change, in which case you will receive notice from us at least 10 days prior to the payment being collected. You authorize Coto Distributors, Inc. to charge your Bank Account or Debit/Credit Card indicated below for agreed upon past due Invoices (7 days after receipt of merchandise will be considerate due, unless other arrangements have been made in writing with Coto Distributors Inc).Bank or Card *Select One OptionBank AccountCredit / DebitCheckboxesBusiness CheckingBusiness SavingsPersonal CheckingPersonal SavingsRouting NumberAccount NumberAccount Holder NameBank NameCredit/Debit Card DetailsCreditDebitCard TypeVisaMaster CardDiscoverAmerican ExpressCardholder NameCard NumbersExpirationCVVCard Zip CodeCheckboxes *I accept the information is correct and I understand this authorizationI understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Coto Distributors, Inc. in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date; and my information will be saved to file for future transactions. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of Bank Account or Debit/Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Bank or Debit/Credit Card and will not dispute these transactions; so long as the transactions correspond to the terms indicated in this authorization form.By clicking Submit I accept the Privacy PolicySubmit
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