New Customer Registration Form

Ship to:
Business Name
Trade Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Bill to:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Attention of:
Business Facts
ProprietorshipPartnershipCorporationFranchise
If a corporation, under what state?
If a franchise, what company?
YesNo
If you are a new owner, what was the purchase date?

MonthDayYear
OwnedLeasedRented
Mortgage / Holder name
Lessor / Rentor Name
OwnedLeased
If equipment is leased, please name the Lessor:
Complete the following for all corporate officers, partners or an individual proprietor:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
General Information
Type of Business
Number of Employees
Monthly Sales Volume
Types of Products Sold
ex. Tobacco, Candy/Gum, Grocery
Accounts Receivable Information
Accounts Payable Contact

First NameLast Name
Account Payable Phone Number

Area CodePhone Number
Primary Email Address*
Should be Empty:

Accounts Receivable Information