Company Name: Business Type: FEIN: Business License Number: Issuing State: Include a copy of your business license. Florida must include a resale certificate for tax exempt status. Primary Contact: Primary Phone: Alternate Phone: Email Address: Company Website: Billing Information (as it appears on your credit card statement): Street Address: City: State: Zip Code: Shipping Information: Street Address: City: State: Zip Code: Industry References: Reference 1: Account Number: Reference 2: Account Number: Expected Monthly Parts Volume: Are you an existing Customer? Where did you hear about us? Signature
