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Legal Business Name
Date
DBA or other name used
Sole Proprietorship
Partnership
Corporation
Other
State
Billing Address
Phone
Fax
Shipping Address
Phone
Fax
Name
Federal Tax I.D #
E-mail
DNB #
Website
Resale Certification #
Attach Resale Certificate
Attach Resale Certificate
YOU MUST ATTACH YOUR RESALE CERTIFICATE WITH THIS NEW ACCOUNTS APPLICATION **IF YOU DO NOT ATTACH YOUR RESALE CERTIFICATE, YOUR ACCOUNT WILL NOT BE PROCESSED
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