______________________________ , ____________________________ , ___________________________
Trade Name/s (dba/aka)
Government Entity _______________________________________

Billing Address: ____________________________ City __________________ State ________ Zip _________ 

E-mail: ____________________________ Retail Tax Number (Vendors License): N/A ___________________

Phone: ( _______ ) ____________________ Fax: ( ______  ) ___________________ Year Established_______

Federal Non Profit Tax ID # ______________________ Website _____________________________________

Government Type US ______State _______ County___________ City ________________Other_______________ 
Ship To Location: (if different from billing address)

Address ________________________________ City ______________________  State ______  Zip __________

Phone: ( _______ ) _____________________ Fax: ( ______  ) ___________________
List officials / responsible parties:

Name __________________________ Title ___________ Phone ( ______ ) ______________

Address ____________________________ City ______________________ State ______ Zip __________

Name __________________________ Title ____________ Phone ( ______ ) ______________

Address ____________________________ City ______________________ State ______ Zip __________

Bank Name ___________________________  Acct No. _________________ Phone ( ______ ) _______________

__________________________________________________________________________________________
Name                                              Street Address                              City                              State                Zip
References (Firms you purchase from on open account.)

Phone: ( _______ )_____________________ Fax: ( ______ )___________________

___________________________________________________________________________________________
Name                                               Street Address                              City                             State                Zip

Phone: ( _______ )_____________________ Fax: ( ______ )___________________

GOVERNMENT GUARANTEE: This entity will be responsible if our account becomes delinquent and will pay finance charge 
(1.5% per month (18% annual)), and legal fees of seller for collection if they become necessary.

_______________________________________________________________________________________
Printed Name                                  Signature                                  Title                  Date mm/dd/yy

How fast can invoices be paid ____30 days ____  10 Days ____ Days
How many locations do you have? _______ USA ______Overseas
What primary type of entity are you? Military: ___ Army ___ Navy ___ Air Force ___ Marines ___ Other: _________________
School: ___ University ___ College ___ High School ___ Grade School ___ Other: ____________
Prison: ___ Federal Prison ___ State Prison ____ County Jail ___ Municipal Jail ___ Other: __________________


Comments ___________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Estimated monthly purchase volume:__________ dollars OR ____________ pounds
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