"*" indicates required fields Step 1 of 4 0% Customer InformationCustomer Legal Name*As shown on tax returnCustomer Type Company Individual EIN*SSN*Business DBA/Trade NameSales Rep*Select One...Select One...Adam RichardsonDereck DietrichDylan MichaelEd LortsJennifer HessJerry GambleTad OverstreetPrimary Contact Name* First Last TitleEmail* Phone*Fax Billling AddressAccounts Payable Contact Name* First Last PhoneA/P Email* Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping/Service AddressShipping/Service Address Same as previous Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Payment TermsPreferred Billing Method* Prepayment Invoiced (pending credit application approval) Trade ReferencesPlease list three (3) trade references and contact information. A minimum of two (2) must be current vendors.Reference #1Company Name*Name First Last PhoneEmail Relationship Type* Vendor Banking Customer Other Account NumberReference #2Company Name*Name First Last PhoneEmail Relationship Type* Vendor Banking Customer Other Relationship Type* Vendor Account NumberReference #3Company Name*Name First Last PhoneEmail Relationship Type* Vendor Banking Customer Other Relationship Type* Vendor Account Number Payment TermsDoes your organization require purchase orders?* Yes No PO Required on orders totaling more than:Is your organization exempt from Texas Sales and Use Tax?* Yes No Tax Exemption CertificateAccepted file types: pdf, jpg, jpeg, png, Max. file size: 50 MB.Please upload your tax exemption certificatePreferred Method of Payment Check Credit Card (3% processing fee may apply) ACH (please submit authorization form) AuthorizationAuthorization*By clicking below, I certify that the above information is true and accurate to the best of my knowledge. I also certify that I am an authorized agent and allowed to execute this Customer Information Form. I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my bank account for the services provided. I further agree that in the event my banking information becomes invalid, I will provide updated payment information upon request, to be charged for the payment of any outstanding balances owed, and that I may be subject to penalties resulting from late payment. Return and Privacy Policies are available for review at https://safetymed.com/about-us/. I agreeName* First Last TitleThis field is hidden when viewing the formUser IPThis field is hidden when viewing the formDate MM slash DD slash YYYY Δ
