COD/Credit Card Customer Application





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