mDesign

Business Contact Info

Business Name

Business Address

Business City

Business State

Business Zip/Postal

Same as Bill To

Bill To Name

Bill To Address

Bill To City

Bill To State

Bill To Zip/Postal

Business Country

Number of Ship to Locations

1 2+

Ship to Name

Ship to Address

Ship to City

Ship to State

Ship to Zip/Postal

Is the 'Ship To' a:

Business

Residence

Ship to List (optional)

Attach List if there are 2+ Ship To locations

Final Destination Country

Points of Contact

Name & Title

Website

Phone

Fax

Invoice Email

AP Contact

AP Phone

AP Email

AP Fax

This form was prepared by someone other than customer listed? (ie. a rep)

Yes

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Financial Information

Payment Method

We will Prepay

We would like to set up Terms

For prepayment we accept all major credit cards.

Please list at least 5 resources that can give credit information for your company. Please include phone numbers and fax numbers. The use of fax numbers will expedite your credit check and shorten the delivery time of first order..

Ref. 1

Phone

Fax

Account Number

Ref. 2

Phone

Fax

Account Number

Ref. 3

Phone

Fax

Account Number

Ref. 4

Phone

Fax

Account Number

Ref. 5

Phone

Fax

Ref. 6

Phone

Fax

Account Number

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Tax Information

VATIN

Please submit a "Resale Certificate" for any and all states that product would be shipped. Upon receipt of the certificate(s), your account would be set up accordingly so that no state sales tax will be charged.

Exemptions for other reasons are also permissable, such as non-profit entity or non-resellers.

Form 1

Form 2

Form 3

Form 4

Form 5

Form 6

Add more

Business Contact Info

Points of Contact

Business Info

Additional Info

EDI Capabilities

Financial Information

Tax Information