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Bill To:
Exact Name :
Subsidiary:
Address:
City/State/Zip:
Phone:
   Fax:
E-mail:

Ship To:
Check here if Ship To address is the same as above. Please fill out below if different.
Name:
Address:

City/State/Zip:
Attn:
Phone:
   Fax:
Web (URL) Address:

General Business Information:
Type of Business:
  DBA Individual
  Partnership Corporation
Years in Business:
Year of Inc.:
State of Inc.:
Officer's Name:
Title:
ARE YOU TAX EXEMT?
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   Identification
Number:
Accounts Payable Contact:
Name:
Phone:
   Ext.:

Bank Reference:
Bank Name:
City/State/Zip:
Officer Handling:
Phone:
   Ext.:

Business Credit Reference: List minimum of three
1. Name:
Address:
City/state/Zip:
Phone:
2. Name:
Address:
City/State/Zip:
Phone:
3. Name:
Address:
City/state/Zip:
Phone:
We certify that all information on this form is correct; and that we fully understand your credit terms and agree to the proper payment in consideration of extended credit.

Additional Information:
Purchasing Contact:
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Approximate number of employees:
In office Outside Office
Please let us know where you heard of us:
Special delivery instructions:
Do you require a P.O. for every order?
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*Angleshelf Of Puerto Rico Inc. respects your privacy and promises not to use this information in any manner inconsistent with the purpose intended.