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BUYER REGISTRATION
First Name:
Last Name:
Governmental Agency or Non-Profit Organization:
Address 1:
Address 2:
City:
State:
Zip/Postal:
Phone:
Email:
PAYMENT INFORMATION
Agency Authorized Procurement Officer:
Procurement Officer Phone:
Procurement Officer Email:
Will you be using Purchase Orders?
Yes No
* You must use a State Procurement Credit Card. No personal cards are accepted.
Credit Card #:
Issued to:
Expiration Date: (mm/yy)
SHIPPING INFORMATION
(This information can be changed during order checkout)
Name:
Company:
Address 1:
Address 2:
City:
State:
Zip/Postal:
Phone:
Email:
Username: (Please select a Username 6-10 characters)
*Your Password will be sent to you via (Buyer)email once
your registration has been approved.
Note: Only individuals approved by your agency may purchase from Prison Industries.
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