Primary Contact Information

Name

First Name *

Last Name *

TItle

Email *

Phone *

Company Information

Legal Business Name *

DBA

Address

Employer Identification Number (EIN) *

Business Owner's Name(s) *

Business Type *

Business References

Reference #1

Company Name *

Contact Name *

Phone *

Reference #2

Company Name *

Contact Name *

Phone *

Reference #3

Company Name *

Contact Name *

Phone *

Bank Reference

Bank Name *

Bank Contact *

Bank Phone Number *

Payment Preferences

Send Invoices via: *

Email

Mail

Purchase Order Required? *

Yes

No

Are your purchases Tax Exempt? *

Yes

No

If you answered "Yes" to Tax Exempt: please send Tax Exempt documentation to [email protected] for verification.

How does your company usually pay invoices? *

Check

Credit Card

EFT/ACH

Other

If Accounts Payable differs from Primary Contact, complete below:

Accounts Payable Contact Name

First Name

Last Name

Accounts Payable Email or Mailing Address *

Credit Application Authorization *

I am an authorized representative of my company that has the authority to make credit\purchasing decisions and hereby authorize the release of any information necessary to assist in establishing a line of credit with CSI.

Authorized Representative Electronic Signature *

Today's Date *