Customer Application

NOTE: Items marked with an asterisk (*) must be completed

Check one:*
Individual
Partnership
Individually Owned Business
Corporation-Corp. Guarantee

Name of Business*
Address*
City, State, Zip*
Telephone*
Fax*
Owner
How long in Business?
Tax Number*
Resale Lic. Number*
DUNS Number*
Please complete the information below for your trade references:
Company Name*
Contact Name
Address
City/State/Zip
Telephone*
Fax*
Email
Length of business relationship with vendor (in years):
Company Name*
Contact Name
Address
City/State/Zip
Telephone*
Fax*
Email
Length of business relationship with vendor (in years):
Company Name*
Contact Name
Address
City/State/Zip
Telephone*
Fax*
Email
Length of business relationship with vendor (in years):

 

 

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