COMPANY INFORMATION:

FFSSC Sales Rep *

Date of Application *

Co. Trade Name *

Co. Legal Name

Year Company Founded *

Type of Organization *

State Where the Organization was Formed (multiple options)

COMPANY INFORMATION (CONT.):

Email *

Phone *

Business Address (location of service) *

City *

State *

Zip Code *

Website

BILLING INFORMATION (IF DIFFERENT):

Billing Email

Billing Phone

Billing Address

Billing City

Billing State

Billing ZIp Code

BUSINESS PRINCIPALS:

Owner *

Owner Email

Owner Phone

President *

President Email

President Phone

Manager *

Manager Email *

Manager Phone *

Accounts Payable *

AP Email *

AP Phone *

SALES TAX EXEMPTION:

Is Your Organization Exempt From Sales Tax? *

If Exempt, Please Upload Certificate of Sales Tax Exemption Here (Required for Tax Exemption):

County of Business *

Purchase Order Required? *

Any Other Standard Billing Instructions?

Upload Completed W9 Form Here *

BANK REFERENCE:

If you have a document with your bank/trade references, you can upload that document here.

Bank/Trade References Document

Bank Name *

Bank Account Number (Last 4 Digits) *

Bank Address *

Bank Phone Number *

Bank Contact Name *

AGREEMENT:

Your electronic signature below is accepted by the parties as authorization for us to contact the bank and any trade references. Minimum initial order for open account is $100. TERMS are NET 30 DAYS. Finance charge of 1.5% per month on all past due balances. Should the account be placed for collection, ALL legal fees, court costs, & any associated cost of collection plus interest@ 1.5% per mo. will be paid by applicant.

Check the Box and Sign Electronically to Agree *

I authorize Fire Fighter Sales & Service Co. to contact my bank and/or any trade references submitted here, and agree to all terms of service as outline above.

Signature *

Clear

Full Name & Title *

Today's Date *

Your Sales Rep *