Billing Address (if different from above):
Incorporated in what state:
Number of years in business:*
PRINCIPAL BUSINESS OFFICER (owner/partners/officers)
Are Purchase Order Numbers required for your business?*
Is your business exempt from Virginia Sales & Use Tax?*
(if so, please send to email@example.com, VA ST-10, Sales & Use Tax Exemption Certificate)
Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter. I fully understand your credit terms are due payable by the 30th of the month following purchase. I also understand that a FINANCE CHARGE of 2% per month may apply to all balances over thirty days past due. Reasonable collection and attorney costs may be added when required.
All references listed are hereby requested to release information required to process this information.