New Client Information Form
Customer Information
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Invoice Submission Preference
*
Email
Online Portal
Invoices Submitted to the Attention of ...
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Accounts Payable Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Customer Authorized Contact/Quote Approver
*
First Name
Last Name
Location Info (Site)
Company
*
Is the Site Address the same as the address provided above?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Site Contact
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Vendor Requirements
Redblue's preferred method of payment is ACH. Please provide documentation required for ACH payments.
A 3% Service Fee will be added to all credit card payments.
Regular Hours: 7:30am - 4:30pm
Minimum 2 Hours + Vehicle Charge for Diagnostic Call
Service time begins when Technician is dispatched and is rounded to nearest half hour.
Payment Terms are Net 30
Please indicate documentation required by your company for payment
*
W-9
Certificate of Insurance (Please attach a copy of your insurance requirements)
Tax Exempt (Please provide copy of certificate)
PO # Required on Service Billings (*Note: PO Number must be received prior to service)
No documents required
Other
Name of Representative Submitting This Form
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: