| *Company
|
DBA |
|
| *FED. TAX I. D.
NO. (or SS# if SOLE) |
TAX EXEMPT? No Yes (Provide a copy of certificate.) |
| *ADDRESS
|
ADDRESS 2 |
|
|
*CITY |
*STATE |
*ZIP |
|
SHIP TO ADDRESS (if different from above) |
||
|
ADDRESS |
ADDRESS 2 |
|
|
CITY |
STATE |
ZIP |
| COMPANY CONTACT |
| *FIRST NAME |
*LAST NAME |
|
TITLE |
*EMAIL (if any) |
|
*PHONE |
FAX |
|
Check one for
Notification of Credit Decision Fax Phone E-mail |
|
| STRUCTURE OF
ORGANIZATION: |
STATE OF
ORGANIZATION |
| TYPE
OF BUSINESS |
YRS.
IN BUSINESS |
| YRS. UNDER
PRESENT CONTROL |
|
|
D. & B. NO. |
| CREDIT REQUIRED | |
|
| PRINCIPAL'S
FIRST NAME(1) |
PRINCIPAL'S LAST
NAME(1) |
SOCIAL SECURITY
NO.(1) |
| HOME PHONE
|
% OWNERSHIP
|
TITLE |
| ADDRESS
|
ADDRESS |
|
| CITY |
STATE |
ZIP |
|
||
| PRINCIPAL'S
FIRST NAME(2) |
PRINCIPAL'S LAST
NAME(2) |
SOCIAL SECURITY
NO.(2) |
| HOME PHONE
|
% OWNERSHIP
|
TITLE |
| ADDRESS
|
ADDRESS |
|
| CITY |
STATE |
ZIP |
|
||
AUTHORIZATION
AND ACKNOWLEDGEMENT  I hereby certify that all information contained in this application
and all attachments hereto is true and complete to the best of my
knowledge, and has been supplied for the purpose of establishing
contact information. I authorize to verify any and all of the information with the source(s) it deems appropriate and further authorize any of the
above banks and trade references to release requested information. I understand that this constitutes an
application only and shall not bind Miami Business Telephone,
Inc or any other party.
|