Customer Number Application

Application Type (check one or both):

Please check the appropriate box below.

* Legal Business or Organization Name

* Website

* Bill To Address

* City

* State

* Zip

* Phone

Fax

How will you receive your orders most frequently?

Ship To Address (if different than bill to)

City

State

Zip

Phone

Fax

Employer Identification Number

* Owner's Name

NOTE: If you do not have a Federal Employer Identification Number (EIN), please provide 2 proofs of business such as a: voided business check, business license, state certificate of business registration, membership in a professional association, trade association or chamber of commerce. Additional information may be requested to set up your account. For more information, contact our Customer Service Department.

* Would you like to apply for credit terms?

* Would you like to put your credit card information on file?

By checking "Yes", a sales representative will contact you to receive your information. Credit applications are available separately.

*Main Contact Name

* Phone Number

* Email Address

Buyer 1 Name

Phone Number

Email Address

Buyer 2 Name

Phone Number

Email Address

Admin/Accts Payable Name

Phone Number

Email Address

Do you require a Purchase Order # or Job Name on your orders?

Please list any other special ordering details:

* Are you tax exempt?