Company
Name:
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Billing
Address:
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Shipping
Address:
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City: | State: | Zip: | |
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Telephone: | Fax: | ||
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Corporation: | Partnership: | Proprietorship: | Other: |
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State of Incorporation: | Year Business Started: | ||
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Type of Business: | |||
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List two officers, partners or owners: |
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Name: | Title: | ||
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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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1. Name: | Address: | ||
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Telephone: | Fax: | ||
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Other References: |
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1. Name: | Address: | ||
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Telephone: | Fax: | ||
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2. Name: | Address: | ||
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Telephone: | Fax: | ||
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3. Name: | Address: | ||
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Telephone: | Fax: | ||
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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 |