Business Name * Business Type * Phone * E-mail Address: * Fax * Mailing Address * City * State * Zip * Delivery Address City State Zip Primary Target Market * Years in Business * Tax Id Number * Business is a Corporation, Partnership, or Sole? * If Corporation, which states are you incorporated? Name of Principle Owner(s) or Partners * Authorized Buyers & Titles Desired Payment Terms Credit or Open(may take up to 4 weeks for approval; credit application must be completed) * If Credit Visa, MC, Discover or AE? Annual Sales Volume * Do you require purchase order numbers? yes or no * Accounts Payable Contact * Authorized Name * Title of Authorized * Date * * Required