New Credit Card Customer Account Information Form All Items Must Be Completed. If "Not Applicable" Please Write N/A Name of Person Completing this Form Legal Name of Firm Doing Business As (DBA) Street Address City/State County Zip Phone # Fax # Taxable Yes No If Yes, enter your County If No, please attach your state's tax exemption certificate Bill To Information Name on Invoice P.O Box Street State/Zip A/P Supervisor Ship To Address (If Different) Name on Invoice P.O Box Street State/Zip Purchasing Agent
