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Date
Sales Rep (if known)
Company Name
DBA
Federal Tax ID/SS#
Type of Business
How long in business?
Website
Billing Contact Name & Phone Number
Billing Contact Email
Billing Address
Billing City, State, Zip
Shipping Address
Shipping City, State, Zip
Ownership Type (Sole Prop, Corp, Partnership, etc)
Has the firm or any of its Principals ever filed bankruptcy?
Account Contact
Account Contact Title
Account Contact Phone
Account Contact Email
Trade Reference
Phone