FFR-DSI - Retail merchandising products and solutions at FFR-DSI

Subtotal:

$0.00

Online Catalog

Company Information:

Customer#:

Full Business Name

dba

Bill-To Address:

City:

State:

ZIP:

Ship-To Address:

City:

State:

ZIP:

Phone

Fax

Email Address:

Tax Exempt?

YesNo

Are P.O.'s required?

YesNo

CorporationPartnershipProprietorship

Federal ID#

If Partnership or Proprietorship, complete the following:



Principal Name	S.S.N.
Address	City	State	ZIP
Type of Service/Product Provided		Year Established

Credit References:


Financial Institution		Account Number
Address	City		State	ZIP
Contact Name	Phone			Fax

Supplier		Account Number
Address	City		State	ZIP
Contact Name	Phone			Fax

Supplier		Account Number
Address	City		State	ZIP
Contact Name	Phone			Fax

Supplier		Account Number
Address	City		State	ZIP
Contact Name	Phone			Fax

* Applicant, if granted the privileges of an account, agrees to pay in full all invoices ordered within 30 days. FFr reserves the right to assess a finance charge on any balance over 30 days delinquent and that assessment may be up to 2% per month or 24% per year. By submitting this document, the applicant is providing FFr with permission to make any inquiries FFr deems necessary in order to grant applicant terms. Applicant further agrees to reimburse FFr for actual and reasonable collection charges and legal fees incurred if the account becomes delinquent.

Applicant Name			Title

Date: