::: Van Sickle Paint Company :::

Main Office & Distribution Center: 5700 N.W. 38th Street Lincoln, NE 68524 P.O. Box 82222 Lincoln, NE 68501-2222 Ph: (402) 476-6558 Toll Free: (800) 677-2468 Fax: (402) 476-6749 - - - - - - Factory: 305 M Street Lincoln, NE 68508 Please fill out this form, we will contact you soon with the requested information.

Name:
Company:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
	Your comments and feedback are always helpful.

	Are you a: Retail Customer Dealer/Retail/Farm/Hardware Store Distributor Ag-Service Center Member of a buying group (if so, note group)
	Please note your estimate annual purchases in gallons or dollars (if known)