Billing Account Application

Your Name*

First NameLast Name

Email*

example@example.com

Office Phone*

Please enter a valid phone number.

Direct Phone (Cell/Ext.)

Please enter a valid phone number.

Legal Company Name*

Position/Title at Company*

I hereby affirm that I am a duly authorized representative of {legalCompany} and possess the legal authority to submit this billing account application on behalf of the company. By signing below, I acknowledge and accept the responsibility of setting up and managing the billing account for {legalCompany}.

Your Signature*

Autofill from Above ?

YesNo

Name*

First NameLast Name

Legal Company Name*

Position/Title at Company*

Email*

example@example.com

Office Phone*

Please enter a valid phone number.

Direct Phone (Cell/Ext.)

Please enter a valid phone number.

Company Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is Company Mailing Address Different from Billing?

YesNo

Company Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How would you like to receive invoices? (You may choose more than one method)*

EMAIL - All invoices for company/organization will be emailed directly to provided email address (specify in field below).MAIL - All invoices for company/organization will be mailed directly to provided mailing address above.TURN IN - A copy of the invoice will be given to the person who picks up and they will be responsible for turning it in.

Invoice Email*

example@example.com

Preferred Payment Terms*

NET 15 (payment due 15 days from invoice date)NET 30 (payment due 30 days from invoice date)NET 60 (payment due 60 days from invoice date)Other

Would you like us to require authorization to charge account?*

YesNo

What type of pre-authorization will be required?

Require Purchase OrderAll orders must be quoted and sent for approval to above contactAll orders must be quoted and sent for approval to alternate contact (enter below)Purchaser must have a company email addressPurchaser must have a company credit card w/matching photo IDPurchaser must provide a valid business card w/matching photo IDOnly specific people are allowed to charge this account (enter names below)Other

Quotation Approval Contact

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Enter names of authorized purchasers

	First & Last Name	Phone Number	Email Address	Position/Title
Contact 1
Contact 2
Contact 3
Contact 4
Contact 5

Additional Notes/Comments:

Optional File Upload

Example: Upload a list of authorized purchasers

By submitting this form, you acknowledge and agree to all Capital Trophy terms and conditions, as well as the policies outlined above. For more information, please refer to the details provided at the top of this page and our Policies Page.

REQUESTER CONTACT INFORMATION

COMPANY/ORGANIZATION INFORMATION