Company Name:
Bill To Address:
Ship To Address:
City:
State:
Zip Code:
Key Contact Name:
Person Name filling out this form:
Contact Email Address:
Dee Sales Contact: (person you are working with at Dee)
Tax Exemption ID # (if applicable):
Phone #:
Fax #:
Accts Payable Fax # or A/P Email Box for Invoicing: *
* We will invoice electronically via Fax, Email, or EDI only - no paper invoices will be sent
Description of what your Business is:
Number of Employees in your Company:
Annual Sales $ of your company:

We must have 4 Existing Credit References filled out:
Credit Reference Company #1:
Credit Ref #1 Phone:
Credit Ref #1 Fax:
Credit Ref #1 Credit $ Limit:

Credit Reference Company #2:
Credit Ref #2 Phone:
Credit Ref #2 Fax:
Credit Ref #2 Credit $ Limit:

Credit Reference Company #3:
Credit Ref #3 Phone:
Credit Ref #3 Fax:
Credit Ref #3 Credit $ Limit:

Credit Reference Company #4:
Credit Ref #4 Phone:
Credit Ref #4 Fax:
Credit Ref #4 Credit $ Limit: