New Customer or Change to Acct #      with  Add’l Address   Change to existing information

 

Customer Name:       

 

Parent (Main) Address:    Bill to this address     Bill to ship to address

 

Address line 1      

Address line 2      

                        City           State      Zip       -      County       (please provide if known)     

 

            Attn:        (should use Accounts Payable unless customer instructs otherwise)

 

Ship To Address:  (for multipleship to addresses please send additional sheet listing addresses)

 

            Ship To Name:      

            (if not same as customer name)

             

Address line 1      

Address line 2      

  City         State      Zip       -      County      

                       

           

 

            Payment method:  Pay by Check     Pay by Credit card only

                       

            Credit Limit Requested $      fax credit application to Janet Simmons at (314) 372-2011

           

Is this a Government entity? Yes   No  Please note this on credit application as well

           

            Taxable?  Yes   No    fax exemption certificate to Linette Q. at (314) 372-209

 

            Customer Accounts Payable Contact Name:                 

 

Send Invoices to customer via:    E-mail       Fax        Mail 

 

Customer A/P Phone #:(   )                  Customer A/P Fax #:(   )      

                                                                        Required if sending invoices via fax

Customer A/P E-mail Address:      

            Required if sending invoices via e-mail

             

            Submitted by: 

 

Sales Partner Name:                Sales Partner #           Division:      

 

            Will commissions to this customer always be split with another partner?  Yes   No   

If yes- Sales Partner Name:         SP#         % to other partner