New Client Consultation Form

Application for a New Account

Thank you for the opportunity to earn your business
Account Name*
Red Asterisk Denotes Required Field throughout this form
TAX ID NUMBER*
Bill to Address*

Address

Street Address Line 2

CityState

Zip CodeCountry
County*
please list your bill to county
Phone Number*

Area CodePhone Number
Ship to Address

Street Address

Street Address Line 2

CityState

Zip Code
County*
please list your ship to county
Phone Number

Area CodePhone Number
Accounts Payable Contact*

First NameLast Name
Accounts Payable Email*
example@example.com
Accounts Payable Phone*

Area CodePhone Number
Purchasing Contact

First NameLast Name
Purchasing Phone Number

Area CodePhone Number
Purchasing E-mail
example@example.com
DEA NUMBER WITH EXPIRATION DATE*
DEA NUMBER AND EXPIRATION DATE
Is Your Business Tax Exempt*

YesNo
Sales Person Name (at AMS)*
Credit Limit Requested
How Would You Prefer to Pay your bills? (PLEASE FILL OUT INFO BELOW)*

ACH Draft at time of ShipmentACH Draft on the 29th of the MonthCredit Card at time of shipment *additional CC form will be provided for CC information
ACH INFORMATION Bank Name
BANK NAME
ACH INFORMATION Routing Number
ROUTING NUMBER
ACH INFORMATION Account Number
BANK ACCOUNT NUMBER
Your Full Name*

First NameLast Name
Signature*

Sign with your mouse on PC or Finger/Pen on Mobile
Should be Empty:

Application for a New Account