Fill out and submit our online request to become a new customer and a sales representative from Diversified Controls, Inc. will be in contact with you.

    Company Information

    Company Name:

    Company Address:

    Company City:

    Company State/Province:

    Company Zip:

    Company Country:

    Company Phone (required):

    Company Contact Email (required):

    Company Fax:

    Company Billing Information

    Same as Company AddressDifferent Company Address

    Billing Company Name:

    Billing Address:

    Billing City:

    Billing State/Province:

    Billing Zip:

    Billing Country:

    Billing Phone (required):

    Billing Email (required):

    Billing Fax:

    Invoice Submittal:
    EmailUS Mail

    Accounting details

    Accounts Payable Name:

    Accounts Payable Phone:

    Accounts Payable Email:

    Sales Tax:

    Exempt Number:

    Bank details:

    Bank Name:

    Bank Officer/Contact:

    Bank Telephone:

    Bank Fax:

    Bank Email:

    Business References (Valve Companies/ USA Companies):

    Company 1 Name:

    Company 1 Telephone:

    Company 1 Fax:

    Company 1 Email:

    Company 2 Name:

    Company 2 Telephone:

    Company 2 Fax:

    Company 2 Email:

    Company 3 Name:

    Company 3 Telephone:

    Company 3 Fax:

    Company 3 Email:

    Additional Details:

    How would you prefer to be contacted?: (required):