New Customer Account Request

All fields are required below. Incomplete forms will delay the process.

If you are requesting 30 day terms rather than COD, please select "Yes" for "Apply for Credit/Terms".

All COD accounts must have a credit card on file.

Requested By*:

Please enter your name.

InterTech Account Manager:

Please enter the Account Manager's name.

New Customer/Company Name*:

Please enter your company name.

Mailing Address*:

Please enter your mailing address.

City*:

Please enter your mailing address city.

State*:

Zip*:

Please enter your mailing address state.

Please enter your mailing address zip.

Shipping Address*:

Please enter the shipping address.

City*:

Please enter the shipping address city.

State*:

Zip*:

Please enter the shipping address state.

Please enter the shipping address zip.

Authorized Purchaser(s) on Account*:

Please enter the authorized purchaser(s).

Is this Customer Tax Exempt?*:

YesNo

Please make a selection.

PO's Required?*:

YesNo

Please make a selection.

Legal Structure*:

CorporationPartnershipPropietorship

Please indicate the legal structure.

FEIN:					Please enter the FEIN.
Year of Inc.:		State of Inc.:			Please enter the year of incorporation. Please enter the state of incorporation.

Apply for Credit/Terms?:

YesNo

Please make a selection.

Accounting Contact Information

Contact's Name*

Enter contact's name.

E-mail Address*

Enter valid e-mail.

Phone*

Enter contact's phone.

Fax*

Enter contact's fax.

Sales/Marketing Contact Information

Contact's Name

Enter contact's name.

E-mail Address

Enter a valid e-mail.

Phone

Enter contact's phone.

Fax

Enter contact's fax.

Credit Information

Credit Card # to Keep on File

(in the format of ####-####-####-####)

Enter a credit card number.

Expiration

(##-####)

Enter the expiration date.

Contact Us

New Customer Account Request

Accounting Contact Information

Sales/Marketing Contact Information

Credit Information