Customer Application - Landmark Equipment

Customer Information
New/Existing Customer:*
- New Customer
- Existing Customer
Name/Company Name:*
Fed Tax I.D. #:
Billing Address*
Shipping Address City State ZIP Code
Company Type:
- Corporation
- Partnership
- Proprietorship
Years In Business
Business Phone:*
Fax:
Cell:
Payables Email:*
Purchasing Email:
Preferred Invoice method*
- Email
- Mail
Officers of Company
Name Address Phone Position
Do you require purchase orders?
- Yes
- No
Consent*
I agree to the below conditions.
If this account request is opened, I agree:
1. To pay each invoice no later than 30 days following the date of invoice.
2. To pay interest of 1.5% per month on any invoice past its due date.
3. To pay collection agency fees, attorney’s fees and all court costs in the event that collection efforts become necessary
Authorized Name:*
Title:
Date*
MM slash DD slash YYYY
Signature*