Building): Home/Garage Lease Own Storefront / Shop

Acc. Payable Contact: Purchasing Contact:

Name of Bank: Phone: Account #:

Est. of Monthly Purchase: Taxable: Exempt #:

Owner's, Officer's, Partner's Home Address

Name: Title: Address:

City:     State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Flordia Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Washington West Virginia Wisconsin Wyoming Zip Code:  

Home Phone: Driver's Lic.: DOB :

Name: Title: Address:

City:     State: Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Flordia Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Washington West Virginia Wisconsin Wyoming Zip Code:  

Home Phone: Driver's Lic.: DOB :

Trade References (Include Name, Address, Phone, and Fax Number)

1.

2.

3.

4.

Additional Information:
   I agree the information on this applicaion is true to the best of my
knowledge and agree to pay within the terms of 1% 30 Net 31 Days,
and I agree to pay a time-price differential of 1.5% on any invoices
which are past-due over 60 days regaurdless of whether I get paid
as promptly for the job where the materials were used.

Signiture: Current Date:

For Office Use Only: P.C.: Salesperson #:

Ship Via Territory: Approval: