JK Customer Information Form

JK Customer Information Form

FOR PURCHASES OF LAMPS AND PARTS
CUSTOMER INFORMATION
Company Name
Tax I.D. Number
Owner Name

Prefix First Name Middle Name Last Name Suffix
Phone Number
Please enter a valid phone number.
Email
example@example.com - This email will be used for invoicing.
JK Products Sales Representative *

First Name Last Name
COMPANY INFORMATION
Type of Business
Years in Business
Legal Business Entity Type

CORPORTATION PARTNERSHIP PROPRIETORSHIP Other
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
BANK REFERENCE
Institution Name
Account No.
Contact Person

First Name Last Name
Branch Location
BUSINESS REFERENCES
REFERENCE 1
Company Name
Contact Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Credit Limit
Current Balance
Year Acct. Opened
REFERENCE 2
Company Name
Contact Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Credit Limit
Current Balance
Year Acct. Opened
FINANICAL INFORMATION
Company Total Assets
Company Total Liabilities
Annual Net Income
Annual Total Expenses
Have you or your officers or affiliates ever filed a petition in bankruptcy (circle one)?

YES NO
Is your company subject to any litigation (circle one)?

YES NO
If yes, please describe
INVOICE DELIVERY
Email for invoices
example@example.com
All invoices are emailed unless a paper copy is requested. To receive a paper copy of your invoice mailed to you, please fill out the billing information below.
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Agreement

By signing below, we declare that the above information is true, correct and complete to the best of our knowledge.If we are granted credit, we agree to pay all invoices within 30 days of the date of the invoice. We are authorizing JKProducts & Services, Inc. to contact the trade references listed on this application and our bank as needed for thepurpose of determining credit worthiness.
Signature *

Clear
Date

Month Day Year
Date
Signature

Clear
Date

Month Day Year
Date
Printed Name

First Name Last Name
Title
Printed Name

First Name Last Name
Title
DISCLAIMER: JK in its sole discretion may request additional information for the consideration of payment terms.

411 WEST WASHINGTON AVENUE, SUITE B | JONESBORO, AR 72401

Toll-Free: 888.771.0996 | Fax: 870.935.3618
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JK Customer Information Form

CUSTOMER INFORMATION

COMPANY INFORMATION

BANK REFERENCE

BUSINESS REFERENCES

FINANICAL INFORMATION

INVOICE DELIVERY

Agreement