Customer Account Setup Form
This information will help DuraPlaq meet your needs and get you setup with a prospective customer account. We look forward to having the opportunity to earn your business!
Name
*
First Name
Last Name
*CALC NAME
Email
*
example@example.com
Online Form Submission Date
-
Month
-
Day
Year
Date
Type of Business
*
Professional Artist / Photographer
Amateur Artist / Photographer
Retailer (Print / Frame Shop)
Corporation / Franchise
Interior Designer
Art Consultant
Contractor
Gallery
Personal Use
Other
Company Name
Company Website
Billing Address
Street Address
City
(Select One)
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
INTERNATIONAL
State
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Mobile Number
-
Area Code
Phone Number
Is Your Shipping Address The Same As Your Billing Address
Yes
No
Shipping Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are You A Tax Exempt Entity or Have a Sales Tax License For Resale Purposes
Yes
No
Resale License Number
State of Sales Tax Registration
(Select One)
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
INTERNATIONAL
Please Upload a Copy of Your Sales Tax License or Exemption Letter Below If Available
Browse Files
Cancel
of
Sales Tax Exempt Form
Please Upload a Copy of Above Sales Tax Exempt Certificate To Complete Tax Exempt Status (Can Be Submitted at a Later Date)
Browse Files
Cancel
of
Sales Tax Type
TAX EXEMPT
Out of State
Tax Mead Colorado
Tax Denver Colorado
TN State Sales Tax (7%)
Out of State - STL ON FILE
Colorado State Sales Tax
Do You Have a Dedicated Accounts Payable Contact?
Yes
No
Accounts Payable Contact
Accounts Payable Email
example@example.com
Accounts Payable Phone Number
-
Area Code
Phone Number
Accounts Payable Email
example@example.com
Do you require a copy of the invoice be sent to any other Contacts?
Yes
No
Does the Accounts Payable Dept Have the Same Address as the Primary Company Address?
*
Yes
No
Accounts Payable Address
Street Address
City
(Select One)
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
INTERNATIONAL
State
Postal / Zip Code
Preferred Payment Method
Credit Card
Cash Upon Pickup
Credit Terms* (Pending Credit Approval)
Check
I Will Establish Payment Preference Later
Submit
Should be Empty: