Customer Information Sheet
PhaseCore | AmbuBus | Decon | PPE | DPR | Preparedness
Customer Information Sheet
Complete this form and email it to sales@ (or fax to 703-955-7540).
Customer Information
Company/Agency Name: __________________________________________________________________________________________________________________ Address: _____________________________________________________________________________ P.O. Box: __________________________________________ City: ________________________________________________________________________________ State: ______________ Zip: __________________________ Phone: ______________________________________________________________________________ Fax: _______________________________________________ Toll Free Phone: ______________________________________________________________________ Fax: _______________________________________________ If located in CA, please list your CA tax ID number: ____________________________________________________________________________________________
Billing Address
Name (if different from above): _____________________________________________________________________________________________________________
Address: _____________________________________________________________________________ P.O. Box: __________________________________________
City: ________________________________________________________________________________ State: ______________ Zip: __________________________
Preferred Invoice Method:
email: _____________________________
fax: _______________________________
mail (using address above)
Shipping Address
Address: _____________________________________________________________________________ Loading Dock Available:
Yes
No
City: ________________________________________________________________________________ State: ______________ Zip: __________________________
Contact: _____________________________________________________________________________ Phone: ____________________________________________
Times Open: ________________________________________________________________________ Email: _____________________________________________
Key Contacts
Technical Contact: ___________________________________________________________________ Title: ______________________________________________ Phone: _____________________________________________________________________ Email: _____________________________________________
Accounting Contact: __________________________________________________________________ Title: ______________________________________________ Phone: _____________________________________________________________________ Email: _____________________________________________
Sales Contact: _______________________________________________________________________ Title: ______________________________________________ Phone: _____________________________________________________________________ Email: _____________________________________________
Alternate Contact: ___________________________________________________________________ Title: ______________________________________________ Phone: _____________________________________________________________________ Email: _____________________________________________
Other Contact: _______________________________________________________________________ Title: ______________________________________________ Phone: _____________________________________________________________________ Email: _____________________________________________
General Information (Please answer all questions)
Customer Type:
Individual
Company
Government Agency
Other
Briefly describe company/agency's primary endeavors: ________________________________________________________________________________________
How did you first hear about First Line Technology? ___________________________________________________________________________________________
May we contact you by email with a customer review survey?
Yes
No
Best Email: _______________________________________
Signature: __________________________________________________________ Date: ________________________________
FOR OFFICE USE ONLY
Date Received: _________________________
Customer Number: _______________________
Approved: __YES __ NO
Rev 1_06032013
First Line Technology, LLC
3656 Centerview Drive, Suite 4 | Chantilly, Virginia 20151 USA Tel: 703.955.7510 | Fax: 703.955.7540 | Toll Free: 866.556.0517
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