ACCOUNT APPLICATION

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Account Application
* Denotes Required Field(s)
Company Information
Your Name: *
Your Email: *
Your Job Role:
How did you hear about us?
Company Name: *
Website:
Billing Address
Address: *
Suite:
City: *
State: *
Zip: *
Phone: *
Shipping Address
Address: *
Suite:
City: *
State: *
Zip: *
Phone: *
Purchasing Information Request
Purchase Order required?: *
Authorized to purchase: *
First Name * Last Name * Email Role  
 
Add Another
Accounting contact name: *
Accounting contact direct phone number: *
Accounting contact email: *
Fed ID #: *
Tax Exempt Status: *
Tax Exempt Number: *
Terms Choice: *
Statement & Invoice copies: * All statements and invoices will be emailed to your AP contact email or other designated representative.
Statement & Invoice Email: *
Statement & Invoice Fax: *
Terms
  • I understand terms are Net 30 from date of invoice unless I opted C.O.D. terms.
  • I understand I need to submit three credit references within five business days.
  • I understand I need to submit a copy of the tax resale certificate within five business days.

Email to: sally@millerindustrial.com

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