Please select the type of customer that best describes you.

Roofing Contractor

Siding Contractor

General Contractor

Homeowner / DIY

Distributor

Customer Name *

First Name

Last Name

Phone *

(###)

###

####

Phone Type *

Cell

Home

Office

Preferred method for receiving future promotional information.

Please check all that apply. Permission for representatives of Murphy's Roofing Supply to contact me via the method(s) selected above has been granted by the above mentioned.

Call

Text

Email

Prefer not to receive promotions

Project Type *

Check all that apply

Shingles

Flat Roof

Siding

Other

Do you expect to have additional roofing projects? * *

Yes

No

Construction Site Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you needing the material delivered to the job site? *

Yes

No

Have you purchased from us before? *

Yes

No

Please select your preferred shopping location. *

Hammond, IN - 920 150th St

Chicago, IL - 6830 S. Cottage Grove Ave.

Biloxi, MS - 211 Magnolia St

How did you learn about shopping with us? *

Returning customer

Contacted by a Sales Rep

Internet Posting (Facebook, Craigslist, etc)

Billboard Advertisement

Personal Referral

Other (Please elaborate below)