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We are pleased you have selected _________________________ Inc.  Below is some basic information we need in order to establish your account.  Please complete this form and return it to _________________________ Inc., attention new accounts.


Company Name:  _________________________________________________

Contact:  ___________________________________________

Billing Address:  _______________________________________________________

City:  ________________________ State:  _____________ Zip Code:  ____________

Shipping Address:  ______________________________________________________

City:  ________________________ State:  _____________ Zip Code:  ____________

Phone:  _________________________ FAX:  __________________________

E-mail:  _____________________________


Type of Business:  ____________________________ In Business Since:  __________

Form of Business:  [   ] Corporation  [   ] LLC  [   ] Partnership  [   ] Sole Proprietor

Is a Purchase Order required for the work you will have done?  _________

Name of individual(s) with authorization:  ____________________________________

If it is to be a blanket PO, please list the number and expiration date.

Number ____________________                                              Expiration Date ________________

To whose attention should invoices be sent?  __________________________________

Is your work taxable?  ____  If not, please attach signed certificate and list your tax exempt or resellers number:  ____________________________________________

If you which to pay by credit card, please provide information below:

VISA Card Number __________________________________ Exp. Date __________

MasterCard Number __________________________________ Exp. Date __________

American Express Card Number _________________________ Exp. Date _________


Bank References (please list name and address of local banks):





Trade References (Please list name, address, phone number, and account number of three references.  Do not list credit cards.)





Our terms are net 30 days.  Accounts not paid in this time frame will be charged 1.5% interest rate per month and future orders will be on a C.O.D. basis until the account is current.  Should collection or legal action be required to collect past dues, said fees will be added to your account. 


Print Name:  ___________________________ Title:  __________________________

Signed by:  _______________________________ Date:  ___________________

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