Customer Name:

Federal Tax ID EIN:
(Please attach a completed W9)

Sale Tax ID:
(if non taxable please attach completed Certificate)

Physical Address:

Mailing Address:

Main Phone Number:

Main Contact Name:

Contact Email:

POs Required?: YesNo

Accounts Payable Contact Name:

Accounts Payable email for invoices:

Credit Requested:

Terms Requested:

Company Officers Name and email:

Bankruptcies, Lawsuits?: YesNo

BANK Reference INFO

Bank Name:

Bank Address:

Bank Officer:

Bank Phone:

Bank Email:

Please provide 2 TRADE REFERENCES