Name: * Address: * City, State Zip: * Phone: * Fax: Email: * Business Type * Select Sole Proprietor Partnership Corporation 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. reCAPTCHA If you are human, leave this field blank.