General Information

Company name:

State Sale/Resale Tax ID#:

Annual Sales:

Bill-to address:    City:    State:    Zip:

Phone:    Fax:

Email address:

Website address:

Company Owner's name:    Phone number:

Accounts Payable contact:    AP Phone:

AP Fax:    AP Email:

Account Status Applied for:    Dealer:    Distributor:

Payment Terms Requested:    Check/Credit Card:    Open Account:
*Account terms established upon credit check & signed guarantee of credit by authorized company principal

Banking References

Bank Name:

Account #:

Phone:

Trade References

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