General Information
Type of Business: Corporation Partnership Proprietorship
Name of Business:
Email Address:
Office Address:
City: State: Zip:
Phone Number: Fax Number:
Owner/President:
General Manager:
Partners (if any):
Trade Information
Note: Please only list those vendors that sell to you on open accounts.
Name: Account Number: Address: City: State: Zip: Phone Number: Fax Number:
Vendor Information
Does your business require purchase orders? Yes No
List name(s) of person(s) authorized to request service for your business.
Name: Title: Name: Title: Name: Title: Name: Title: Name: Title:
Terms and Conditions
I have read and understand the above terms and conditions. I hereby certify that the business/corporation listed herein is licensed and authorized to conduct business within the State of Alabama.
Name: Title: Email Address: Home Address: City: State: Zip: Phone Number: Fax Number: