Become a Customer Form

BUSINESS INFORMATION
Business Name*

Legal Name of BusinessDBA (if applicable) If not applicable, write "N/A"
Registered Business Address *

Street Address

Street Address Line 2

CityState

Zip Code
Business Details*

Type of BusinessYear Started
Business Structure*
Are you Tax Exempt?*

YesNo

DELIVERY/SHIPPING DETAILS
Shipping Address*

Name of Business

Street Address

CityState

Zip Code
Purchase Order (PO) Required?*

YesNo
Delivery Times and Details*
Please specify hours in which your business can receive deliveries and any special delivery instructions.

ACCOUNTS PAYABLE INFORMATION
Name*

AP First NameAP Last Name
AP Contact Information*

AP EmailAP Best Phone Number
AP Receipt Billing

AP Email for Billable StatementAP Email for Billable Invoice

PAYMENT DETAILS
Terms Requested *

CODCard to ShipNet 30Other
Payment Method*

CheckCredit Card on FileElectronic CheckACHOther
Do you already have a sales rep with us? If so, enter their name below.
Sales Rep

TRADE REFERENCES (required if requesting terms)
Trade References Company A Details

Trade References Company Name

Street Address

CityState

Zip Code
Trade References Company A Contact Information

Trade References EmailTrade References Best Phone Number
Trade References Company B Details

Trade References Company Name

Street Address

CityState

Zip Code
Trade References Company B Contact Information

Trade References EmailTrade References Best Phone Number

FILE UPLOADS
Upload Files

Please upload the following documents, if applicable. a) Tax Exempt Certification b) Credit Information c) Other
Cancelof

AGREEMENT
Printed Name & Title. Please note, this application must be signed by owner or officer.

NameTitle
E-Signature*

Clear
Application must be signed by owner or officer.
Date Signed*
Should be Empty: