Account Application

1. Corporate Information
Industry*
D&B#
Legal Name*
D.B.A. Name

(Business name you'd like to appear on invoices)
Registered Address*
Adresse postale Suite Ville State Zip
Main Account Contact*
Email*
Phone*
Website
Years in Business*
Contractor's License
State of Origin (Contractor's License)
Type of Business*
- Corp
- LLC
- Partnership
- Sole Prop
Tax Exemption
USDOT
2. Billing Information
Purchase Order Required?*
- Yes
- No
Job Number Required?*
- Yes
- No
Attn To*
FEIN / Tax ID#*
Address*
Adresse postale Ville État Code postal
A/P Contact Name*

(Accounts Payable)
Phone*
Fax
Email*
Information on Principals*
Name Position Phone Email

FOR PROPRIETORSHIP OR PARTNERSHIP: LIST ALL OWNERS AND/OR PARTNERS. FOR CORPORATION OR LIMITED LIABILITY COMPANY: LIST ALL OFFICERS, DIRECTORS, MEMBERS AND MAJORITY STOCKHOLDERS. ATTACH ADDITIONAL PAGE IF NECESSARY.
Trade References*
Vendor Name Email Acct# Terms Credit Limit Highest Balance Last Activity Date Phone

DO NOT INCLUDE UTILITY, RENT, INSURANCE, OR PHONE AS TRADE REFERENCES.
Bank Reference*
Bank Address Phone Fax Contact
3. Customer Portal Information
Users*
Name Email Phone

Please include ALL personnel authorized to make rental decisions in portal.
Regional Sales Manager*

Vendor Name	Email	Acct#	Terms	Credit Limit	Highest Balance	Last Activity Date	Phone

Bank	Address	Phone	Fax	Contact

1. Corporate Information