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| Corporation: | Partnership: | Proprietorship: | Other: |
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| State of Incorporation: | Year Business Started: | ||
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List two officers, partners or owners: |
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| Name: | Title: | ||
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| Are purchase orders required? | Tax Exempt? | ||
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* If yes please attach resale or exemption certificate. |
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| Goods purchased for: | Consumption | Resale | |
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Bank Reference: |
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Other References: |
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| 2. Name: | Address: | ||
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| 3. Name: | Address: | ||
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| Signed by: | Title: | Date: | |
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| Our Terms:
Net 30 days Mail to: Brach Machine, Inc., 4814 Ellicott Street Rd., Batavia, NY 14020 or Fax to: 1.585.343.1292 |
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