Customer Information Form - Larson Juhl
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2Customer Information Form
Customer Information
Business Name
Address
City
State
Zip
Business Telephone Number
Cell Phone Number
Business Fax Number
Business E-mail Address
Taxpayer Identification Number
Resale Tax Certificate Number
May we send you promotional, marketing or education information?
Mail
E-mail
No, thank you
n
n
n
Owner Information
Name
Address
City
State
Zip
Title
Home Telephone Number
Social Security Number
E-mail Address
Name
Address
City
State
Zip
Title
Home Telephone Number
Social Security Number
E-mail Address
Have any UCC’s been filed/pledged/collateralized with respect to your inventory, accounts receivable, equipment, property and/or intangibles?
Yes
No
n
n
Have you ever declared bankruptcy or been declared bankrupt?
Yes
No
n
n
Have you ever been an officer or principal shareholder in a dissolved, bankrupt or defunct corporation?
Yes
No
n
n
Optional Business Information
(If established more than 12 months)
Sales
Net Income
Total Assets
Total Liabilities
Number of Employees
Retail Square Footage
This information will remain the exclusive property of Larson-Juhl and will be held in strict confidence.
Please continue on the reverse side
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Parent category: Business