New Customer Information New Customer Form Company NameAddressCityStateZip CodeContact PersonPhoneFaxEmailFederal Tax ID NumberLegal StructureCorporationSole ProprietorshipGeneral PartnershipProfessional AssociationLLCIndividualLimited PartnershipCompany's State of RegistrationDate Business EstablishedCompany's Principals / Officers / Owners (name, title, phone)Sales TaxSales TaxYesNoIf "No" please provide release number or exemption information:Accounts PayableContact PersonPhoneEmailFaxAddressInvoices should be sentEmailMailBothDoes your business require purchase ordersYesNoBank ReferencesBank NameAddressCityStateZip CodeBank OfficerBank PhoneName of Business AccountType of AccountAccount NumberRouting NumberTrade ReferencesCompany, Address, Contact Name & EmailCompany, Address, Contact Name & EmailServicing Site InformationSite NameSite AddressCityStateZip CodeContact PersonEmailPhoneFaxEquipment TypeCTMRIPET/CTX-RayUltrasoundOtherMakeModelSerial #
