Registration Form


!! CURRENT MEMBERS PLEASE LOG ON HERE !!



Thank you for visiting the Zitomer site. You will receive a FREE CATALOG in the mail when you register. You do not need to register to browse our site. Please feel free to explore in complete anonymity. However, if you would like to create or add to a shopping basket, please complete this form. Check out REGISTRATION TIPS! if you encounter any problems. Remember to keep your User Name and Password on hand! You'll need this information each time you re-enter the site and attempt to view personal information. If you ever lose your password, you will not be able to retrieve it. Instead, you will have to re-register under a new name and password.

User Name(NO Spaces):
Email Address:       
PASSWORD:            
VERIFY PASSWORD:     

Below is a brief survey to help us better understand you, our guests and the Internet community at large. This information will help us serve you better when you place future orders.



First Name(*)     
Last Name(*)      
Middle Initial    
Organization      
Title             
Address(*)        
                  
City(*)           
State(*)          
Province(*)       
Country(*)        
Zip(*)            
Day Phone(*)      
Eve Phone         
Fax Number        

All items with (*) must be filled in to successfully submit form.

Do you primarily use:

Mac PC UNIX other

How many people work in your organization?

                       Your       Total
                     Location  Organization

        0-50                   

        51-100                 

        101-500                

        501-1000               

        1001-5000              

        5001-10,000            

        >10,000                



What is your organization's primary business?

Your Function:

Do you wish to be on our Emailing list to receive the latest Zitomer info?
(If No, please skip over the next two questions.)

YES NO

Which products(s) are you interested in?

Any other comments?