Customer Information Form

Who is your primary Contact? *

If you selected "Not Listed", please provide your contact's name here.

If "Not Listed" Contact

Best contact during set up.

Name *

First

Last

Email *

Phone *

Do you use a separate "Bill to" or "Accounts Payable" company address?

If the address is the same as your Company Address above, select "No".
If you want your invoices mailed to a different address, select "Yes".

AP Company? *

No
Yes

Name of Accounts Payable Company (if different from Company Name) *

If the same as your Company Name, just leave blank.

Accounts Payable Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Accounts Payable Contact Name *

First

Last

Accounts Payable Contact Phone *

Accounts Payable Contact Email *

This is the email we will use to electronically send you your invoices.

Do you have a "Parent Company"?

Parent Company? *

No
Yes

Name of Parent Company *

Parent Company Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How would you like to pay?

How would you like pay? *

Credit Card
Payment Terms

A Customer Service Representative will be in touch to collect your credit card payment information.

Trade Reference 1

Trade Reference 1 Business Name *

Trade Reference 1 Phone *

Trade Reference 1 Email *

Trade Reference 1 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Trade Reference 2

Trade Reference 2 Business Name *

Trade Reference 2 Phone *

Trade Reference 2 Email *

Trade Reference 2 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Trade Reference 3

Trade Reference 3 Business Name *

Trade Reference 3 Phone *

Trade Reference 3 Email *

Trade Reference 3 Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

A Customer Service Representative will contact you with your account information.

Thank you for completing our Customer Information Form.

Please read and sign below, then click submit.

A finance charge will be applied at a periodic rate of 1.5% per month (annual percentage 18%) on past due balances over 30 days. Customer agrees to pay within terms of invoice. I further understand that should it be necessary to employ a collection agency or attorney to collect monies due, my firm will be responsible for all reasonable costs of collection. *

Signature

We look forward to working with you!

ClassicPlus is a Matrix Imaging Solutions Company