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Please fill out the form below. Fields marked with "*" are required. If you need assistance with this form, please contact our Customer Service department at 800-964-4940 or 716-689-4556.

*Customer Name
*Date of Shipment	January February March April May June July August September October November December     01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     2008 2009 2010 2011
*Pickup Number or PO Number
*Person to Contact
*Phone
Fax
*Email
Other comments or instructions:
	* denotes required field