NEW ACCOUNT SETUP REQUEST FORM

Corporate Address
Company Name*
Attn:*
Phone*
Fax
Address*
City*
State*
Zip*
Bill To
Company Name*
Attn:*
Phone*
Fax
Address*
City*
State*
Zip*
Corporate Information
CFO or Controller*
Subsidiary or Division of
Dun & Bradstreet Number*
Federal ID Number*
Accounts Payable Contact*
Accounts Payable Phone*
Accounts Payable Email*
Purchasing Contact*
Purchasing Phone*
Purchasing Email*
Organization Form*
State of Incorporation*
Incorporation Date*
Tax Exempt Status*
Tax Exempt Certificate*
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.
Billing Information
Invoices to be sent via*
- US Postal
- Email
- Online Portal
Please provide email address for invoices*
Trade References
Trade Reference One
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Trade Reference Two
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Trade Reference Three
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Bank Reference
Bank Name*
Bank Contact*
Bank Phone*
Address*
City*
State*
Zip*
Account Number*
Checking*
Savings*
Loan*
Agreement
Computex Technology Solutions requires an authorized corporate officer sign that the information listed on this form is true and correct to the best of his or her knowledge. Furthermore giving Computex Technology Solutions permission to contact the Trade References listed above to evaluate credit history.
Applicant Name*
Applicant Title*
Applicant Email*
Applicant Signature*
Email
This field is for validation purposes and should be left unchanged.

Corporate Address
Company Name*
Attn:*
Phone*
Fax
Address*
City*
State*
Zip*
Bill To
Company Name*
Attn:*
Phone*
Fax
Address*
City*
State*
Zip*
Corporate Information
CFO or Controller*
Subsidiary or Division of
Dun & Bradstreet Number*
Federal ID Number*
Accounts Payable Contact*
Accounts Payable Phone*
Accounts Payable Email*
Purchasing Contact*
Purchasing Phone*
Purchasing Email*
Organization Form*
State of Incorporation*
Incorporation Date*
Tax Exempt Status*
Tax Exempt Certificate*
Accepted file types: jpg, gif, png, pdf, Max. file size: 1 MB.
Billing Information
Invoices to be sent via*
- US Postal
- Email
- Online Portal
Please provide email address for invoices*
Trade References
Trade Reference One
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Trade Reference Two
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Trade Reference Three
Company Name*
Contact*
Phone*
Email*
Address*
City*
State*
Zip*
Bank Reference
Bank Name*
Bank Contact*
Bank Phone*
Address*
City*
State*
Zip*
Account Number*
Checking*
Savings*
Loan*
Agreement
Computex Technology Solutions requires an authorized corporate officer sign that the information listed on this form is true and correct to the best of his or her knowledge. Furthermore giving Computex Technology Solutions permission to contact the Trade References listed above to evaluate credit history.
Applicant Name*
Applicant Title*
Applicant Email*
Applicant Signature*
Name
This field is for validation purposes and should be left unchanged.

Corporate Address