Name: *

Address: *

City, State Zip: *

Phone: *

Fax:

Email: *

Business Type *

If Corporation, what State

How long in business? *

Federal Tax ID: *

Name / SSN of individual or Partners or Name / Title / SSN of Corp Officers: *

E-Billing Email Address: *

Name of Person to Contact Regarding Purchase Orders and Invoices, Title, Address, and Phone: *

Bank Reference: Account Number, Contract Title and Phone Number: *

Trade References: Company Name, Address, Contact and Title, Pbone Number: *

The above information is submitted for the sole purpose of opening an account and I hereby certify the information to be true. Name, Title, Date: *

Note: Our payment terms are Net 7 Days from bill date unless other arrangements have been made. At NET 30, there will be a late fee charge. (Example: if we receive your payment NET 31, you will be assessed a finance charge on your balance due.) Here are the terms: 18% per annual year - (1.5% per balance due) Minimum $25.00 late fee (per invoice) We will assess calculated charges from the DATE of the invoice. *

By checking this box, I have read and agree to the payment terms.

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