Customer Information Form

Customer Information Form
Date*

MonthDayYear
T&J Contact Person

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent Company Name:
Phone Number:*

Area CodePhone 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

CityState / Province

Postal / Zip CodeCountry
A/P Contact Name:*
Phone Number*

Area CodePhone Number
A/P Email Address:*
Fax Number

Area CodePhone 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

CityState / Province

Postal / Zip CodeCountry
Contact Name:*

First NameLast Name
Phone Number:*

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

ServicePartsRentalEquipment Purchase
Types of Terms Requested:*

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

Area CodePhone Number
2.
Phone Number

Area CodePhone Number
3.
Phone Number

Area CodePhone Number
Signature:*

First NameLast Name
Phone Number:*

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