Customer Form

Please take the time to fill out the form below as many times neccessary.

The information is stictly private and confidential. And Helps us, to help you!

Customer Data

Customer No.


Mr. Mrs. Other

First name, Last name

Farm Name, Account

Rd, Street

City / Town, Dairy No.

Telephone, Cell Phone

E-mail

Sharemilker

Telephone, Cell Phone

Insert your farm map here

Fertiliser Forecast

Fertiliser (A)

Tonnes

Rate (Kgs)

Month – Due Date

Fertiliser (B)

Tonnes

Rate (Kgs)

Month – Due Date

Fertiliser (C)

Tonnes

Rate (Kgs)

Month – Due Date

Merchant


The orders are split in charge or delivery

Miscellaneous

Further, relevant information.

Please...

... The merchant order(s) have been placed

... I will fax you a copy of the farm map

... Contact me by phone for confirmation

... Contact me by e-mail for confirmation

... I proactive in my farm plan for the future

... send me your newsletter



Click 'Submit' To Send


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Last changed: 06/25/2001, 19:14:00