CORPORATE APPLICATION FOR DEALERS & CONTRACTORS
Company Name
*
Fed Tax ID#
*
Address
*
Zip
*
City
*
State
*
Phone
*
Fax
Mobile Phone
Best Time to Contact You
Type of Business
*
# of Employees
*
Email Address
*
Incorporated
*
Yes
No
LLC
*
Yes
No
State Incorporated
Date Incorporated
Subsidiary
Parent Company
Address
Zip
City
State
Financial Statement
Yes
No
D&B Rating
Years in Business
*
BILLING INFORMATION
Bill To
*
Attn:
*
Title
*
Billing Address
*
City
*
State
*
Accounts Payable Contact
*
Phone
*
Zip
*
Special Billing Instructions
*
NAME OF PRINCIPALS
President/Owner
*
Address
*
SS#
*
Vice President
Address
SS#
BANK REFERENCES
Bank
*
Address
*
Account #
*
Contact
*
Phone
*
Bank
Address
Account #
Contact
Phone
CREDIT REFERENCES
Company
*
Address
*
City
*
State
*
Zip
*
Type of Business
*
Contact
*
Phone
*
Company
*
Address
*
City
*
State
*
Zip
*
Type of Business
*
Contact
*
Phone
*
By signing this application, you agree that Paver Lighting, LLC.. and/or an affiliate company may investigate the information supplied by you. This investigation may include your character, general reputation, style of living, and your credit rating (as supplied by a national credit reporting agency).
Signature of Applicant
*
Title
*
Date
*
CREDIT CARD AUTHORIZATION
Name
*
Credit Card Type
*
Please Select
VISA
MasterCard
Discover
AMEX
Credit Card Number
*
Address
*
Name on Card
*
Phone
*
Expiration Month
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Expiration Year
*
Please Select
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2022
Verification Number
*
Credit Card Billing Address
*
Issuing Bank
*
City, State of Bank
*
In the event payment is made by credit card, I agree to a 5% administrative fee.
Card Holder's Signature
*
Date
*
Submit Form
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