Phone: 602-393-1907 Fax: 602-489-5295 5017 E. Washington :: Suite 105 :: Phoenix 85034

Date: / /    
Business Name:
dba:
Billing Address:      
Address:
Physical Address:      
Address:
Phone : Fax :  
Federal Tax ID #: Dun & Brad #:  
Year Company Established: Sales Tax Exempt?
 Yes
No
ResaleTax Certificate #: (You must attach a copy to this form.)  
Legal Entity:    
President or Principal: Title:  
Purchasing Contact: Phone:  
Accounts Payable Contact: Phone:  
Are purchase orders required? Yes
 Are job names required? Yes
No No
Bank Information    
Bank Name: Bank Contact:  
Bank Address:    
Phone: Email:  
Trade References      
Reference One:      
Company: Contact:  
Address:  
Phone: Email:  
Reference Two:      
Company: Contact:  
Address:  
Phone: Email:  
Reference Three:      
Company:   Contact:  
Address:  
Phone: Email:  
I understand that the information provided is for the purpose of establishing a line of credit and all invoicing.
  / /  
Signature   Date  
Print Name and Title      

Please print this form along with a copy of your Resale Tax Certificate – we cannot process credit applications without a copy of your Retail Tax Certificate (click the “Print Form” button on the right) and fax it to: 602-489-5295
 
Phone: 602-393-1907 Fax: 602-489-5295 5017 E. Washington :: Suite 105 :: Phoenix 85034