Business Contact Information

Business Name or Legal Name of Customer*

Legal Entity Type*

Shipping Location

Address*

State / Province

Country*

City

County*

Zip Code

Billing Address

Address*

State / Province

Country*

City

County*

Zip Code

Business Contact Information

Phone*

Email Address

Fax

Description of Business

Type of Business*

Predominant Trade*

Federal Tax ID

Business Start Date

D&B Duns Number

Number of Employees

Accounts Payable Information

AP Contact First Name*

AP Contact Last Name*

AP Phone*

AP Fax

AP Email*

AP Invoice Email*

POD (Proof of Delivery) Email Address*

Bank Reference

Trade Name

Trade Address

Trade Account

Trade Phone

Bank Name

Bank Address / Branch

Bank Account #

Bank Phone

Trade References

Reference 1

Company Name

Contact Name*

Phone*

Email*

Address*

Reference 2

Company Name

Contact Name*

Phone*

Email*

Address*

Reference 3

Company Name

Contact Name*

Phone*

Email*

Address*

Terms & Conditions

Terms and Conditions (AUTHORIZED SIGNATURE REQUIRED)

Purchaser certifies that it is solvent and capable of meeting its obligations hereunder, and that all information provided to seller is true, accurate and complete. All such information has been submitted for the purpose of obtaining credit. Purchaser authorizes Pure Masonry Products to request credit reports from credit bureaus (including consumer reporting agencies) regarding their respective commercial or personal credit and other wise to investigate their respective credit worthiness before extending credit now or any time in the future. Purchaser agrees that all Terms and Conditions of Sale, as the same may be amended by written notice to Purchaser from time to time, shall apply to all sales and extensions of credit made to Purchaser by Seller.

Accept Terms & Conditions

I have read and agree to the Terms and Conditions of Sale, as the same may be amended from time to time by notice to Purchaser, which shall apply to all sales and extensions of credit made to Purchaser by Seller.

Signed Electronically By*

Signee Title*

Signee Email*

Date

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