New Account Application New Account Application Business Personal Please choose account type Name * Name First First Last Last Phone Email * Company Name * Business structures * Sole Proprietorship Partnership Corporation Year in Business * D-U-N-S Number Credit Line Request $.00 Type of Business * Address * Address Address Suite/Floor Suite/Floor City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Address Name of the person in charge of transportation * Name of the person in charge of transportation First First Last Last Title Phone * Email * Billing Attention * Billing Attention First First Last Last Title Phone * Email * List of Senior Office * List of Senior Office First First Last Last Title plus1 minus1 Specical requesrs Payment Term A late charge of 1.5% per month, equal to 18% per year, will be charged on any overdue amounts. We also agree to pay any collection costs and/or attorney fees that may be incurred due to our account being in arrears. TERMS 15 DAYS NET The above information is submitted specifically and for the sole purpose of opening an account with XYZ Two Way Radio Service Inc. In accordance with the price schedule presented. TERMS 15 DAYS NET I hereby certify the information to be true. I have read and accepted the payment terms and conditions. Initial * signature keyboard Clear Please Initial Signature * signature keyboard Clear Date Sign Name * Name First First Last Last Captcha If you are human, leave this field blank. Submit Save Draft Start Over
