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Business Name: _________________________________________________ Name of Owner(s) in Full: _________________________________________ Shipping Address: ________________________________________________ Billing Address: __________________________________________________ Phone: _______________________ Fax: ________________________ email address: ______________________________________________ Business is Operated As: Proprietor _______ Partnership _______ Corporation ________ Principal Business: ________________________________________ Annual Sales Volume: ______________________________________ D&B #: ________________ D&B Rating: ___________________ 1. _________________________________________________________________ 2. _________________________________________________________________ 3. _________________________________________________________________ Bank Reference: ____________________________________________________ Account# _________________ Contact ___________________ Bank Authorization: I hereby grant permission to the above named bank to release account information to Systems Unlimited, Inc. ________________________________________________________(Name & Title) Sales Tax Status: Charge Tax_______ Resale_______ Tax Exempt (attach certificate)________ |