Preferred Client Application

Company Name

Federal Tax ID #

you File Company

DBA (If Applicable)

D&B #

Billing Address

Address Line 1

Address Line 2

City

State

Zip Code

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Year Established

Please Indicate Your Company's Line of Business

Requested Terms (Check One)

Net 30
Credit Card
Check Prepayment/Wire/ACH

ACCOUNTS PAYABLE

INVOICE RECEIPT CONTACT INFORMATION:

Name

First

Last

Email

Phone

INVOICE FOLLOW UP CONTACT INFORMATION:

Name

First

Last

Email

Phone

SALES TAX

Are you exempt from sales tax?

Yes
No

File Upload

Max file size: 20MB. If you are tax exempt, please include your tax exemption certificate(s) with application for all states where product will ship.

REFERENCES*

BUSINESS TRADE:

Business Name

Contact Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Account #

BUSINESS TRADE:

Business Name

Contact Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Account #

BUSINESS TRADE:

Business Name

Contact Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Account #

* Standard “Bank & Trades” form accepted. Credit card references not applicable.

File Upload

Max file size: 20MB

The information provided above is accurate to the best of my knowledge. The undersigned agrees to payment terms of Net 30, unless otherwise indicated by contract. Unpaid invoices shall bear an interest rate of 1.5% per month until paid in full. Continued delinquency may result in loss of terms or termination of account. Manufacturers’ warranties and return policies apply to all sales. Most software and custom-build items are non-returnable & non-refundable. The undersigned grants permission for information from their references to be released.

Name of Authorized Representative

First

Last

Title

Date