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Company Info

Company Name

Ship to Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Remit To Address

Company Name

Remit To Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

Website

Federal Tax ID

Sales Tax Exempt Certificate #

Duns #

Owners, Principals and Officers

First Name

Last Name

Title

Corporate Headquarters (HQ)

Corporate Headquarters (HQ) Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Bank Reference

Bank Name

Bank Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Number

Phone

Fax

Contact

Email

Accounts Payable Contact

Name

Accounts Payable Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

Purchasing Contact

Name

Purchasing Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Fax

Email

Trade References

Company

Address

Phone

Email

Contact

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