New Customer Setup Form

New Customer Setup Form
Business Information
Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone #
Format: (000) 000-0000.
Account Contact Information
Account Contact Name
Title
Telephone
Format: (000) 000-0000.
Email
example@example.com
Billing Information
Billing Contact Person
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Phone #
Format: (000) 000-0000.
Billing Email
example@example.com
Billing Term
Are you tax exempt on towing services?
Tax Exempt #
Upload Tax Exemption Certificate

Cancelof
P.O. # Required?
You hereby agree that you are authorized to set up this account on your companies' behalf. Any services performed by Capital Towing & Recovery must be paid for in accordance with the terms set forth above.
Signature
Print Name
Title
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Business Information