Customer Information Form : OneSource Building Technologies

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Customer Information

Customer Rep:

Contact Email Address:

Invoicing Requirements and Accounts Payable Contact

Person Our Billing Department Should Send Our Invoices too:

First Name:

Last Name:

Email:

Phone:

Fax:

How do we invoice you?

Are you exempt from sales tax? (If yes, please provide an exemption certificate)

Is a P.O or Work Order Required?

Is there a monthly cutoffdate?(If yes, please provide the day or date)

Person our credit department should contact concerning payment question:

First Name:

Last Name:

Phone:

Email:

Fax:

PLEASE COMPLETE THE FOLLOWING APPLICATION FOR CREDIT IF REQUESTED

Business Credit Information:

Federal Tax I.D.(if incorporated):

Prinipal Business or Firm:

Year Business Established:

At Present Location Since:

Is Business Incorporated?

Inc.,under laws of what state?

Credit Line Requested(USD)?

Dunn & Bradstreet#

Bank References:

Bank Name:

Account Number:

Contact:

Address:

City:

State:

Zip Code:

Country:

Phone:

REFERENCES - PLEASE PROVIDE THREE (3) TRADE REFERENCES

Company Name:

Contact:

Account #:

Address:

City:

State:

Zip Code:

Country:

Phone:

Company Name:

Contact:

Account #:

Address:

City:

State:

Zip Code:

Country:

Phone:

Company Name:

Contact:

Account #:

Address:

City:

State:

Zip Code:

Country:

Phone:

Printed Name:

Date: