New Customer Form

Company Name(Required)

Check here if Ship To is The Same as Bill To

They Are The Same Address

Bill To Address(Required)

Street Address Address Line 2 City State ZIP Code

Ship To Address

Street Address Address Line 2 City State ZIP Code

Purchasing Contact Name

First Last

Purchasing Phone

Purchasing Fax

Purchasing Email

Accounting Contact Name

First Last

Accounting Phone

Accounting Fax

Accounting Email

Engineering Contact Name

First Last

Engineering Phone

Engineering Fax

Engineering Email

Preferred Method To Receive Invoices(Required)

Street Address Address Line 2 City State ZIP Code

Preferred Phone(Required)

Preferred Fax

Preferred Email(Required)

Tax Exemption?(Required)

Yes

No

Please Attach Tax Exemption Form

Max. file size: 64 MB.

Sales Tax Exemption Number(Required)

Trade Reference #1 Name

Trade Reference #1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade Reference #2 Name

Trade Reference #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Contract and Release of Credit Information

Mechatronic Solutions payment terms are NET 30 DAYS. The payment due date is calculated from the date on the invoice. I hereby agree that the organization is bound to the Terms and Conditions that accompany our invoices unless otherwise indicated from an employee of Mechatronic Solutions.

Title of Signer

Date

Email

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New Customer Form

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763 - 447 - 3407

11200 73rd Ave N