Mar Vel International Registration Form

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					Address: 7100 Airport Hwy
          Pennsauken, NJ 08109
Phone:     856-488-4499
Fax:       856-488-4343
Toll Free: 800-325-5711
Website: WWW.MAR-VEL.COM
Email:     mhaberle@mar-vel.com




                                         Prime Vendor
                                   Customer Profile Information
 Primary Buyer’s Name:

 Name of Organization:
                                                                                                      ( MAR-VEL Use Only )
 Organization’s Address:                                                                                Prime Vendor’s
                                                                                                         Internal ID #
                                                                                                         ______________
 Billing Address
 (if different from above):


 Phone Number:                                Fax Number:

 DODAAC/UIC:
 Email Address:

 _________________________________________________________
                                                     Confidential
                        (For Government Credit Card Users Only. Leave Blank if does not apply.)

 Credit Card Number:

 Expiration Date:                                           Credit Card Type

 Name of Authorized User:                                         Signature:
                    ___________________________________________________________
                                        Official Government Website Access Information

 User Name/Login:             Your login will be your Email Address. Once we receive this Prime Vendor Customer Profile
                              Form we will contact you via Email with your password which you may change after login.


    Milstrip Registration (DOD use only)


                                             FAX: 856-488-4343