Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Customer Information Form Please complete this form with the required information. .... ATTENTION: If you would like to apply for payment terms, you will have the opportunity to provide those details in the section below. Accurate and complete information will help us process your request efficiently. Business Information: Business Information: Name of Business: *DBA or Trade NameBilling Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBusiness Type *LLCPartnership*Sole ProprietorshipCorporation*Federal Tax ID # *If Non-profit or for Resale, Tax Exempt #Upload Tax Exempt File Click or drag a file to this area to upload. Only if you are claiming tax exempt statusWhat is the major product(s) or service(s) your business offers? *How long have you been in business?Years *Whole numbers onlyMonths *Whole numbers onlyContact Information: Primary Contact Info:Name *FirstLastPhone *Email *Billing Contact Info:Contact Name / Billing Department *Phone *Email *Request 30 Day Invoicing Would you like Net30 day invoicing terms? *--- Choose Yes or No ---YesNoWhat is a typical budget per project you would foresee needing Net 30 payment terms for? *Reference Bank Information: are with Federal Bank Full Address *Bank Phone *Trade Reference Information *Trade Reference Phone *Trade Reference Email2nd Trade Reference Information *2nd Trade Reference Phone2nd Trade Reference EmailTo protect you from unauthorized use of your account, please provide us with the names of individuals who are authorized to place orders:Payment Terms & Conditions Consent *I agree to the terms and conditions listed belowBy checking this box and signing below the undersigned agrees to the following terms. Payment terms are invoices are payable thirty days from the date of invoice. The undersigned agrees that a service charge of 1½ percent per month may be added to past due balances. In the event of payment default the balance and company account will be referred to a collection agency. The undersigned will be responsible for additional fees applied by the collection agency. If legal action is required, the undersigned is responsible for reasonable attorney's fees resulting from such action. The undersigned authorizes Alphagraphics to contact the above listed bank(s) and/or trade references to establish customer authenticity and business credibility.Payment Options We offer convenient payment options, including: e-Payment (AHC) Credit Card (3% Surcharge) Debit Card Cash Checks Signee's Name *FirstLastSignee's Title *Center InformationChoose the center you primarily do business with: *-- Choose a Location --AlphaGraphics American ForkAlphaGraphics BoiseAlphaGraphics HelenaAlphaGraphics Idaho FallsAlphaGraphics JacksonAlphaGraphics LoganAlphaGraphics MissoulaAlphaGraphics OremAlphaGraphics RexburgAlphaGraphics South Salt LakeAlphaGraphics St. GeorgeAlphaGraphics Twin FallsGraphikSpeedy CPSWhat's the name of your Sales Representative? *Submit
