Reseller Information

Legal Business Name:
DBA (if applicable):

Address:
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Phone:		Fax:
Website:

Reseller Certificate #:

based in

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 Key Company Contacts:

	President	Customer Service	Purchasing
Name:
Email:
Accounting Contact:
Name:
Email:		Phone:	Fax:

In an effort to conserve paper,Electriduct will send the invoices via email. If you would prefer to receive the invoices via US mail, please check this box.

Electriduct will send invoices to the Accounting Contact email listed above. If you would like the invoices to be sent to a different email address instead, please enter it here:

 How did you hear about Electriduct?

Magazine      Trade Show      Electriduct Email Campaign      Online Search

Referred by      Other 

 Purchasing Information:

Business Entity:  Incorporated   Sole Proprietor   Partnership   DBA  

Year Established:			# of Employees:
D&B Number:			Fed Tax ID:

Payment Preference

Credit Card   Prepayment   Open Terms   Other:

Amount of Credit Requested: $

I agree that if approved, Credit Terms will be NET 30 days

** Minimum order requirement of $250 for first Purchase Order **

 Bank Reference:

Bank Name:    Account #:

Contact Person:   Phone:   Fax:  

 Credit References: