Customer Name(Required) First Last Entity/Farm Name Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(Required)BrandHawkinsW&AProduct Name(Required) Machine SN #(Required) Purchase Date(Required) MM slash DD slash YYYY Date of First Use(Required) MM slash DD slash YYYY Dealership Dealership LocationSalesperson Name Primary Crops(Required) Corn Soybeans Cotton Rice Wheat Vegetable Pulse (Check all that apply)General Farm Size(Required) 0-500 500-1000 1000-2000 2000-5000 5000-10,000 10,000+ AcresT-Shirt Size(Required) S M L XL XXL XXXL Δ
