New Customer Application

A confidential application must be completed by each new customer.

Please completely fill in all areas and submit application.

Business Type

Estimated Amount 1st Order

Fed Tax ID / Or Business License Number

Legal Company Name

Doing Business As

D&B (DUNS #) (If Available)

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

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Email Address

Fax Number

(###)

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Accounts Payable Contact Person

If Sole Proprietorship, List SS#

Majority Owner of Business

Banking Information

Bank Name

Checking Account #

Bank Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Bank Phone Number

(###)

###

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Bank Officer / Contact

Credit Line Facility (Lender)

Loan Account #

Creditor Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Loan Officer / Contact

(###)

###

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Supplier References

Supplier 1 Name

Supplier 1 Phone Number

(###)

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Supplier 2 Name

Supplier 2 Phone Number

(###)

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Supplier 3 Name

Supplier 3 Phone Number

(###)

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