New Customer Signup

Customer Name*

(Job Location)

Company Name*

(Corporate Name)

Owner Name*

First Last

A/P Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Ship to Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(Job Location)

A/P Contact*

FAX*

A/P E-mail*

Phone*

Alt. Phone

D&B #

Describe Business

Corporation, partnership, proprietorship and federal ID #.

Federal ID #

Credit Line Desired

(If Applicable)

Who is onsite manager/administrator?

Tax Exempt?*

Yes
No

Sales Tax Exempt #*

Please attach resale certificate.

Preferred Payment Method*

Trade References: three required

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company

Phone*

FAX

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company

Phone*

FAX

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company

Phone*

FAX

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company

Phone

FAX

Bank Reference and Release

Name of Bank*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

By signing this Credit Application, we hereby authorize the above-named bank and trade creditors to release credit information concerning our company and account shown above to be used exclusively for the purpose of credit evaluation. All information given will be held confidential. Applicant(s) signature attests to the financial responsibility, ability, and willingness to pay invoices in accordance with terms of sale from date of Invoice. The above information is for credit and financial responsibility.

BY SIGNING BELOW, THE PERSON(S) EXECUTING THIS DOCUMENT ACKNOWLEDGES THEY HAVE READ OUR TERMS AND CONDITIONS OF SALE

Date

Printed Name*

Title*

Phone*

JMEE Account Rep. Name

JM Electronic Engineering, Inc.

Trade References: three required

Bank Reference and Release

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