Pemco New Customer Form

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Name of Business *

Billing Address *

Street Address *

Nature of Business *

Telephone & Fax *

Business is: *

Corporation

Partnership

Individual

EIN# or SSN# *

Principal(s) *

Name & Title of person to contact concerning the account *

Email & Phone# of contact person *

Name of Principal Bank *

Account Number *

Officer in charge of account

Telephone of bank

Sales Tax Status *

Taxable

Tax Exempt (please attach exemption certificate)

Estimated Monthly Purchases

Please list FIVE trade credit references (include complete phone & fax numbers)

Please review

As evidenced by including my name below, the information on this application is true and factual and provided to Pemco Lighting Products for the purpose of buying materials on credit. Permission is granted to contact references or any other sources to obtain credit information. We agree to make payments in accordance with invoice terms and to pay monthly service charges on overdue balances assessed at the rate indicated on invoices. The undersigned warrants that the individual executing this application is authorized by the applicant to do so and to bind the application to the liabilities and obligations set forth.

I have read the above & agree with the terms (please type your full name & title) *

Date submitted *

YYYY

Submit

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