New Customer Request Form

Company Name*

Trade Name/DBA (if different than above)

Corporate Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Address (If different than above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Telephone Number*

Tax ID/DUN's Number*

Sales Tax Exempt Number*

Is Company Publicly or Privately Held?*

Company Website

President/CEO*

Name

Accounts Payable Name*

Name

Accounts Payable Phone*

Accounts Payable Email*

Accounts Payable Fax #

Accounts Receivable Name*

Name

Accounts Receivable Number*

Accounts Receivable Email*

Accounts Receivable Fax #

Controller Receivable Name

Name

Controller Number

Controller Email

Controller Fax #

Buyer 1 Name*

Name

Buyer 1 Number*

Buyer 1 Email*

Buyer 1 Fax #

Buyer 2 Name*

Name

Buyer 2 Number*

Buyer 2 Email*

Buyer 2 Fax #

Prepaid Account Only*

Credit Card
Certified Check
Wire Transfer

Please check your method of payment

Resale Tax Cert./Tax Exemption*

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 512 MB, Max. files: 3.

Please upload a copy of you Resale Certificate or Tax Exempt Certificate. *Note* You will not be able to send this form without uploading your document(s)

Return Policy*

I agree to the return policy.

Claims should be made within 60 days from receipt of goods and before goods are used. Goods should not be returned without prior written conset.

New Customer