Name of Business (Billing Address)

• COMPANY NAME:
• PHONE:
• FAX:
• STREET:
• CITY:
• STATE:
• ZIP CODE:
• D& B:
• TAX ID:

Ship to Location

• STREET:
• CITY:
• STATE:
• ZIP:

Form of Business

• PROPRIETORSHIPPARTNERSHIPCORPORATIONOTHER

Accounts Payable Contact

• NAME:
• TITLE PHONE:
• EMAIL:

Bank Reference

• BANK NAME:
• ADDRESS:
• BANK CONTACT:
• PHONE:
• FAX:
• BANK ACCOUNT NO.:

Trade References:(Minimum of 3 are requested)

• VENDOR NAME:
• ADDRESS:
• PHONE NUMBER:
• FAX NUMBER:

• VENDOR NAME:
• ADDRESS:
• PHONE NUMBER:
• FAX NUMBER:

• VENDOR NAME:
• ADDRESS:
• PHONE NUMBER:
• FAX NUMBER:

To establish an account,please fax your Sales Tax Exempt Certification along with the signed Credit Check Authorization Form to 704-489-6745

Download Credit Check Authorization Form