Business name:

Billing Address:

City: State: Zip:

Shipping address:

City: State: Zip:

Website URL:

Name of Owners/Officers:

Name: Title:

Name: Title:

Accounts Payable Contact: Accounts Payable Phone:

Accounts Payable Fax number: Accounts Payable Email Address:

Purchasing Agent: Purchasing Phone:

Purchasing Fax number: Purchasing Email Address:

Type of Business:

Date of Business Establishment: / /

Product Lines or Services Rendered:

Federal Tax I.D. #: Tax Status: Taxable Non-taxable

If Not Taxable, please send or fax your tax exemption certificate. Without a valid tax exemption certificate, we are required to charge sales tax.

Amount of credit requested: $