New Customer Information Form

New Customer Information Form

Please complete all sections to help us set up your account with Burners Incorporated.
Company Information
Primary Contact Name

First NameLast Name
Primary Contact Title
Primary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Contact Email
example@example.com
Company Name
Contact Information
Main Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Company Website
Main Company Email
example@example.com
Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Billing Address
Billing Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Billing Email
example@example.com
Shipping Address
Is the shipping address the same as the billing address?
Shipping Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Purchasing Contact
Shipping Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Shipping Email
example@example.com
Accounts Payable Contact
Purchasing Contact Name

First NameLast Name
Purchasing Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Tax Exempt Status
Purchasing Contact Email
example@example.com
Accounts Payable Contact Name

First NameLast Name
Authorization
Accounts Payable Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Accounts Payable Contact Email
example@example.com
Is your company tax exempt?
If tax exempt, a state-specific tax exemption form for your state of business and/or our shipping addresses must also be submitted.
Authorization Signature
Title
Date

MonthDayYear
Date
Should be Empty:

New Customer Information Form

Company Information

Contact Information

Billing Address

Shipping Address

Purchasing Contact

Accounts Payable Contact

Tax Exempt Status

Authorization