NEW CUSTOMER SET-UP APPLICATION

In order to expedite your order and get you into our system, please take a few moments to set up your account with us. Your information will be kept private, and no lists of this information will be sold. This information is strictly to establish our business relationship, and determine what, if any, limitations we will need to work within. Completing this form does not establish credit in and of itself. M J Rifkin, Incorporated may require additional information in order to complete this form, and may need to contact you before account eligibility can be determined.

  • Please provide the following business information:
    First name
    Last name
    Middle initial
    Title
    Organization
    Street address
    Address (cont.)
    City
    State/Province
    Zip/Postal code
    Country
    Work Phone
    FAX
    E-mail
    URL
  • What is the primary type of product/service that your business provides?:
    SIC or type of business (e.g. doctor, dept. store, etc.)
  • Please provide the following general ordering information, (if you know what products you generally purchase):
    QTY DESCRIPTION
       

    Purchase order
    Account name
      SHIPPING
    Street address
    Address (cont.)
    City
    State/Province
    Zip/Postal code
    Country
  • Please identify the Owner/President of the business:
    First name
    Last name
    Middle initial
  • Please enter your Federal EIN/SSN#:
  • How much Credit are you requesting (USD only) ?

  • Enter bank name, contact, phone number and account number in the space provided below.

    Choose one of the following options:


  • Enter three trade and/or credit references in the space provided below. Please include Business name, Contact, Phone, and Account Number (when applicable):


    •

    Thank you for your application. You will be notified shortly regarding your account information. Expect excellent customer service, pricing, and turnaround time.

    Return to TABLE OF CONTENTS or press BACK to return to your previous location.

    Copyright ©1999-2005 M J Rifkin, Incorporated, All Rights Reserved.
    Last revised: August 28, 2005