Business or Corporate Name
Mailing Address: City: State: Zip Code: Phone Number:	Street Address: City: State: Zip Code: Fax Number:
Type of entity: Corporation Partnership Sole Proprietorship Individual Government	Federal ID#:
Have you been in business for 3 years or longer? Yes No	Exempt from Sales/Use tax? Yes No
If exempt from Sales/Use Tax, state reason for exemption:
Principal Owners or Shareholders (when applicable)
Name: Name: Name:	Title: Title: Title:
Accounts Payable
Contact Person: Address: City: State: Zip Code:	Phone: Fax: Email: Title: Date:
Purchase Order      Requisition      Voucher      Credit Card
Specific Billing Requirements or Comments:
Our terms are net 30 days. 18% per annum charged on all past due invoices.

Customer Profile
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Business or Corporate Name: Contact Person:
Mailing Address: City: State: Zip Code: Phone Number:	Street Address: City: State: Zip Code: Fax Number:
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