Account Application, Form Tc-721 - Exemption Certificate
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4ACCOUNT APPLICATION
(Required to be completed and signed before credit will be extended)
(PLEASE PRINT)
SALES REPRESENTATIVE:
SHIPPING ADDRESS:
Company Name:
DBA:
Street:
City:
State:
Zip:
STATE SALES TAX EXEMPT? No Yes
Telephone: (
)
FED ID NO.:
(Circle One)
If Yes, form TC-721 (attached) must be submitted.
BILLING ADDRESS (IF DIFFERENT FROM ABOVE):
Street or P.O. Box:
City:
State:
Zip:
Telephone: (
)
(Office)
Type of Business: Corporation:
Partnership:
Proprietorship:
ACCOUNTS PAYABLE:
Name:
Telephone: (
)
E-mail:
OFFICERS OF CORPORATION OR OWNER(S) OF BUSINESS:
Name:
Title:
Street:
City:
State:
Zip:
Telephone: (
)
E-mail:
Name:
Title:
Street:
City:
State:
Zip:
Telephone: (
)
E-mail:
Date Business Started:
How Long At This Location:
Building: Owned
Leased:
Name of Person or Corporation Holding Lease:
BANK REFERENCE:
Bank Name:
Branch:
Account No.:
Account Listed under:
Bank Official:
TRADE REFERENCES (IMPORTANT TO PROVIDE REFERENCE IN THE FOOD INDUSTRY)
Name:
Telephone: (
)
Street:
City:
State:
Zip:
Name:
Telephone: (
)
Street:
City:
State:
Zip:
Name:
Telephone: (
)
Street:
City:
State:
Zip:
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Parent category: Financial