Customer Registration App

Company Information Legal Name * Email * Phone Number * Billing Address *

City *

County/State *

Zip/Postal Code *

Use as Shipping Address

Shipping Address *

City *

County/State *

Zip/Postal Code *

Company Web Address

Business Facts Proprietorship

Type of Business

Years in Business *

Industry *

Buying Group

Date Joining Buying Group

Buying Group Info Tax Exempt Number * Currency * Resale Certificate No * Please attach your Resale Certificate *

Corporate Information Corporate Name * Corporate Title *

Corporate Name 2 Corporate Title 2 Corporate Name 3 Corporate Title 3

Controller and A/P Info Controller * A/P Contact * A/P Phone * A/P Email *

Purchasing Info Purchasing Agent Contact * Purchasing Agent Email * Purchasing Agent Phone

Banking Info Bank Name Account Number Contact Name * Bank Address Bank City Bank State Bank Zip Code Bank Phone

Reference Info

Three required for submission

Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Second Reference

Second Reference Company Name * Reference Contact * Reference Address * Reference Email * Reference Phone *

Third Reference

Third Reference Company Name * Reference Company Contact * Refrerence Address * Reference Email * Reference Phone *