CUSTOMER INFORMATION
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NEW DEALER INFORMATION FORM
CUSTOMER NAME: __________________________________________
TELEPHONE #_____________________FAX#_____________________
E-MAIL ADDRESS__________________WEBSITE_________________
CONTACT: ______________________EXTENSION #_______________
TELEPHONE #_____________________FAX#_____________________
E-MAIL ADDRESS____________________________________________
BILLING ADDRESS: __________________________________________
CITY___________________STATE______________ZIP CODE________
SHIPPING ADDRESS: __________________________________________
CITY___________________STATE______________ZIP CODE________
TYPE OF COMPANY:
SOLE PROPERITOR /PARTNERSHIP / CORPORATION
NUMBER OF YEARS IN BUSINESS OR DATE STARTED___________
FEDERAL ID #________________ OR SS#_________________________
RESELLERS PERMIT #___________
LIST OF OWNER/PARTNERS/ OR OFFICERS:
NAME: _____________________ADDRESS________________________
TITLE_______________________PHONE#_________________________
NAME: _____________________ADDRESS________________________
TITLE_______________________PHONE#_________________________
NAME: _____________________ADDRESS________________________
TITLE_______________________PHONE#_________________________
BANK NAME:_____________________CONTACT__________________
ADDRESS:_________________________PHONE#___________________
ACCOUNT #________________________TYPE : SAVINGS/CHECKING
LIST THREE (3) BUSINESS REFERENCES:
NAME OF BUSINESS: _________________________________________
CONTACT PERSON__________________PHONE#__________________
ADDRESS____________________________________________________
YEARLY SALES TRANSACTION AMOUNT_______________________
YEARS DOING BUSINESS WITH_______________________________
NAME OF BUSINESS: _________________________________________
CONTACT PERSON__________________PHONE#__________________
ADDRESS____________________________________________________
YEARLY SALES TRANSACTION AMOUNT_______________________
YEARS DOING BUSINESS WITH_______________________________
NAME OF BUSINESS: _________________________________________
CONTACT PERSON__________________PHONE#__________________
ADDRESS____________________________________________________
YEARLY SALES TRANSACTION AMOUNT_______________________
YEARS DOING BUSINESS WITH_______________________________
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