NEW CUSTOMER SET-UP APPLICATION

This information is considered confidential and proprietary and will not be used, sold, or otherwise provided to any third parties. It is strictly used for the purposes of establishing a business relationship between M J Rifkin, Incorporated and your organization.

Thank you for completing this application. We will process it as soon as possible. Please be as complete as possible, and if you have any questions, feel free to contact us at (847) 677-4448. This application may be accepted or declined at the sole discretion of M J Rifkin, Incorporated, and completion of this form does in no way qualify the submitter for credit with M J Rifkin, Incorporated.
TERMS: All new customers are expected to provide cash in advance on first order to establish high limit, and 50% advance on future orders, with balance due upon delivery. Company purchase orders are accepted, as are approved company checks. Your credit status may be reviewed from time to time, and you authorize M J Rifkin, Incorporated to verify any sources or information provided herein for the purpose of establishing or increasing credit limit. Some larger orders may require cash in advance in full. Custom work is not returnable except as warranted by the manufacturer, and M J Rifkin, Incorporated assumes no liabilities for products damaged in shipping.

Please Tell Us Who You Are. . .

First Name Mid. Init. Last Name

Title

Please Tell Us About Your Company. . .

Organization
Street Address
Address (Suite, etc.) (Cont.)
City
State/Province
Zip/Postal Code
Country

How Can We Reach You?:

Work Phone
Fax Number
E-Mail Address
URL (Web Site)

What is the primary type of product/service that your business provides? (SIC or type of business (e.g. doctor, dept. store, etc.)

Please tell us what general types of products/services you usually purchase. Are there any specific items or services that we can help with?

If shipping is different than your billing address, please provide the following SHIP TO ADDRESS:

Shipping Information:

Street Address
Address (Suite Number) (Cont.)
City
State/Province
Zip/Postal Code
Country

Please provide us with some necessary company information:

PLEASE IDENTIFY THE COMPANY OWNER/PRESIDENT:

First Name Middle Initial Last Name
PLEASE ENTER YOUR FEDERAL EIN/SSN
Please enter the date the business began in its present form:
Choose one of the following options:

Please Provide Us With Some Basic Credit Information:

How much credit are you requesting?
Please enter bank name, contact, phone number and account number in the following box:



Please enter 3 trade and/or credit references. Include Business name, Contact, Phone, and account number (when applicable)

Can We Meet Again?

How would you prefer we contact you?:


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