New Customer Form Page 2
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4Cust # _____________
New __
Change __
Void __
Date __ __ / __ __ / 20 __ __
BILLING ADDRESS
Trade Name
__________________________________________________________________________________
Contact
__________________________________________________________________________________
St Address
__________________________________________________________________________________
PO Box
__________________________________________________________________________________
City
St
Zip
_________________________________________________
_____
_______________________
Phone
Fax
________ - ________ - _____________
________ - ________ - _____________
Network Account __
Network # ________________________
B/O Code __
Office Use
Cty Code ______
City ______
Fed __
State __
Cty __
City __
Only
Fax Code __ Type _____ Tax Code __ St Code __ Copies __ Credit Terms __
Sales Tax ID _______________________________________________________________________
DELIVERY ADDRESS - if different than billing address
Deliver To
__________________________________________________________________________________
Address
__________________________________________________________________________________
City
State
Zip
____________________________________________________
_____
_____________________
Cty Code __ __ __ City Code __ __ __ Fed __ State __ Cty __ City __
Office Use Only
Company Web Address _____________________________________
Copy of Invoice
__ Yes
__ No
Company Email
_____________________________________
___
Mail
Purchaser Email
_____________________________________
___
Fax to Number Above
Accounts Pay Email
_____________________________________
___
Email
Duns Number
_____________________________________
email: ________________________________
Credit Cards
Do you want to pay for your purchases from Dacotah Paper Co with a credit card? _____Yes _____No
If yes, I authorize Dacotah Paper Co. to initiate a charge to my/our credit card, for all purchases that I/we make from Dacotah Paper Co.
This authorization shall remain in effect until Dacotah Paper Co receives written notice of revocation of authority. Payments made by credit
card are not eligible for any cash discounts.
______________________________________
________________
_____________________________________________
Name/Title (Print)
Date
Signature
Please contact Dacotah Paper Co. with your credit card information as this email form is not secure.
___ Set Up For Internet Ordering
___ No Sub Items
Backorder Options
Special Instructions (Limit One)
__ A - Ship any quantity of item out.
__ Fax Confirmation Copy
__ Get PO Number
__ B - Ship only when out quantity can be filled.
__ Cut Off Prices
__ Get Credit Card Number
__ No UPS Deliveries
__ Do Not Leave Invoice
__ C - Ship when all outs for order can be filled.
__ Get Delivery Address
__ Contract Items Only
__ D - No backorders at all
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Parent category: Business