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Customer application form

Submit / Update Your Company Profile

"(All information contained in this application is for controlled internal use by Amistar Corporation only and will be treated as confidential.)"

*Required Fields in Bold

Company Name:

Your Name:

Your Email:

Business Description:

Resale Tax Number:

Credit Limit Request:

Taxable?

YesNo

Resale Exemption Number:

Tax Rate Percent:

Telephone Number:

Fax Number:

Date Business Started:

Annual Sales:

Billing Address

Address:

City:

State:

Zip:

Country:

Shipping Address

Address:

City:

State:

Zip:

Country:

Contacts

Equipment Buyer:	Equipment Buyer Phone:	Equipment Buyer eMail:
Controller:	Controller Phone:	Controller eMail:
Accounts Payable:	Accounts Payable Phone:	Accounts Payable eMail:

Trade References

Vendor #1 Name:	Vendor #1 Phone:	Vendor #1 Fax:
Vendor #2 Name:	Vendor #2 Phone:	Vendor #2 Fax:
Vendor #3 Name:	Vendor #3 Phone:	Vendor #3 Fax:

Bank Reference

Bank:

Telephone:

Fax:


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