Customer Information Form

Customer Information Form
Date *

Month Day Year
T&J Contact Person

First Name Last Name
Company Information
Legal Company Name: *
Duns ID#:
Billing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Parent Company Name:
Phone Number: *

Area Code Phone Number
Years in Business: *
Federal ID#:
State of Incorporation:
Business Type: *
Billing Information
Is your legal company's name and billing address the same as your company name and billing address:

Yes
Company Name: *
Billing Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
A/P Contact Name: *
Phone Number *

Area Code Phone Number
A/P Email Address: *
Fax Number

Area Code Phone Number
Sales Tax Exempt (if Yes please include form): *
PO Required *
Ship To Information:
Is your company's name and billing address the same as your company name and physical location:

Yes
Company Name: *
Physical Location: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Contact E-mail: *
Primary Purposes of Account: *

Service Parts Rental Equipment Purchase
Types of Terms Requested: *

COD (Cash/Check/Credit Card at POS, some restrictions apply) N10 (Equipment due on receipt)
If requesting terms other than COD, supply 3 trade references:
1.
Phone Number

Area Code Phone Number
2.
Phone Number

Area Code Phone Number
3.
Phone Number

Area Code Phone Number
Signature: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Enter the message as it's shown *
Should be Empty: