Firm Name Phone Fax Billing Address

City/State Zip Street Address City/State Zip _________

Type of ownership: Sole Proprietorship ( ) Partnership ( ) Corporation ( ) Other ( )

Year business began Years at present location_____________

Resale # Corporate Federal I.D. # _____________

Contractors License # Type Year Issued_____________

1. Name Title SSN _____________

2. Name Title SSN _____________

3. Name Title SSN _____________

Accounts Payable Supervisor _____________

1. Name___________________________ 2. Name____________________________

Residence________________________Residence_____________________________

___________________________ __________________________

Social Security #:__________________SocialSecurity #:________________________

Bank Branch Acct.# _____________

Bank Officer Phone _____________

1. Name Phone Fax Address City/State Zip _____________

2. Name Phone Fax

Address City/State Zip

3. Name Phone Fax _____________

Address City/State Zip _____________

I agree to keep within your terms of NET 5 DAYS from receipt of invoice. Should it ever be necessary to employ an attorney or agent to collect or commence suit to enforce payment, I agree to pay a reasonable additional sum to cover the costs involved. All contracts are entered into in Gardena, Los Angles County CA. Rental building customers must maintain adequate insurance for the property.

Authorized Signature Title Date 

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