Preferred Client Application

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PREFERRED CLIENT APPLICATION

* Indicates required field

Company Name: *

DBA (If applicable): *

Billing Address: *

City, State, Zip: *

Phone Number: *

Federal Tax ID #: *

D&B #: *

Shipping Address: *

City, State, Zip: *

Phone Number: *

ACCOUNTS PAYABLE

INVOICE RECEIPT CONTACT INFORMATION:

Name: *

First

Last

Email Address: *

Phone Number: *

INVOICE FOLLOW UP CONTACT INFORMATION:

Name: *

First

Last

Email Address: *

Phone Number: *

SALES TAX

Are you exempt from sales tax? *

Yes No

Upload file *

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: *

Contact Name: *

business name: *

phone / fax: *

address: *

email: *

City, state, zip: *

Account #: *

Business / Trade: *

Contact Name: *

Business Name: *

Phone / Fax: *

Address: *

Email: *

City, State, Zip: *

Account #: *

Business / Trade: *

Contact Name: *

Business Name: *

Phone / Fax: *

Address: *

Email: *

City, State, Zip: *

Account #: *

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

Upload File: *

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 *

Submit