Company Name:____________________________________________________
D/B/A:_____________________________________________________________
Main Address:____________________________________________
For Correspond:__________________________________________
City:_______________________ State:_______________Zip:_______________
Phone:_________________________
Fax:__________________________ Email:_____________________
Contact/Title:_____________________________________________________
Price Structure: Wholesale /Distributor / Retail / State
Is customer sales tax exempt? Yes or No
Or do we have a certificate of exemption received from customer?
Yes or No
Tax Exempt #_______________________________________
Credit Limit Established: $__________________________________
Invoice to be sent to:_______________________________________
(If different from above)
Address:__________________________________________________________
City:______________________ State:_______ Zip:______________
Phone:_____________________ Fax:__________________ Email:_____________________________
Contact/ Title:_____________________________________________
Products to be sent to:______________________________________
(If different from above)
Address:__________________________________________________________
City:_______________________ State:__________ Zip:__________
Phone:________________________ Fax:__________________
Contact/ Title:_____________________________________________
Other information:_________________________________________
__________________________________________________________________ __________________________________________________________________
Return by fax to 1 800 471-3478
