Company Name: ___________________________________________________________
Company Principal: _________________________________________________________
Title: ____________________________________________________________________
Purchasing Contact: ________________________________________________________
Business Phone: ___________________________________________________________
Fax: _____________________________________________________________________
E-mail: ____________________________________________________________________
Business Address: _________________________________________________________
City: _________________________ State: __________ Zip: ______________
Business Established (year): _________________________________________________
Federal Tax ID Number: _____________________________________________________
Dunn & Bradstreet Number: __________________________________________________
Average Yearly Sales Volume: _______________________________________________
Bank Reference:
Bank: ___________________________________________________________________
Bank Contact: _____________________________________________________________
Account Number: __________________________________________________________
Business Trade References:
1) Company: ______________________________________________________________
Contact: _________________________________________________________________
Address: ________________________________________________________________
Phone: __________________________________________________________________
2) Company: ______________________________________________________________
Contact: _________________________________________________________________
Address: ________________________________________________________________
Phone: __________________________________________________________________
3) Company: ______________________________________________________________
Contact: _________________________________________________________________
Address: ________________________________________________________________
Phone: __________________________________________________________________
Please check all of the following that apply:
Our Company is a:
Distributor ________ Broker ________ Re-Seller _______ End User ______
We have an immediate need for your product: YES ________ NO _______
We have a need for your product in:
30 days ______ 60 days _______ 90 days _______ Beyond 90 days _______
The product we have the most interest in is: _____________________________________
Please have a representative contact us: YES ___________ NO ____________