Customer Information Form

Customer Information Form
Date

MonthDayYear
T&J Contact Person

First NameLast Name
Company Information
Legal Company Name:
Duns ID#:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent Company Name:
Phone Number:

Area CodePhone Number
Years in Business:
Federal ID#:
State of Incorporation:
Business Type:
Billing Information
Is your legal company's name and billing address the same as your company name and billing address:
Company Name:
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
A/P Contact Name:
Phone Number

Area CodePhone Number
A/P Email Address:
Fax Number

Area CodePhone Number
Sales Tax Exempt (if Yes please include form):
PO Required
Ship To Information:
Is your company's name and billing address the same as your company name and physical location:
Company Name:
Physical Location:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact Name:

First NameLast Name
Phone Number:

Area CodePhone Number
Contact E-mail:
Primary Purposes of Account:
Types of Terms Requested:

Other
If requesting terms other than COD, supply 3 trade references:
1.
Phone Number

Area CodePhone Number
2.
Phone Number

Area CodePhone Number
3.
Phone Number

Area CodePhone Number
Signature:

First NameLast Name
Phone Number:

Area CodePhone Number
Enter the message as it's shown
Should be Empty: