APPLICATION FOR CUSTOMER BILLING ACCOUNT

Company Information
Company Name
Address line 1
Address line 2
City
State
Zip
Year at this address
Phone Number
Fax Number
Type of Business
   
Principals  
Name of Principal
Title
Complete Address
Phone
   
Name of Principal
Title
Complete Address
Phone
   
Name of Principal
Title
Complete Address
Phone
   
Finance  
Bank Name
Bank Address
Bank Officer or Department
Phone
   
References  
Business Name Business Phone
Business Address
       
Business Name Business Phone
Business Address
       
Business Name Business Phone
Business Address
       
Business Name Business Phone
Business Address
   
TERMS: NET 30 DAYS

If you are not contacted within 24 hours, please call (972) 633-8872 x28