customer information request

This field is hidden when viewing the form
Hash
Kind of request*
- Customer
- Supplier
- Both
Company name*
Dba (if different)
Type of business*
- Corporation
- Sole proprietorship
- LLC
- Partnership
- Other
By signing this form, you: 1. confirm that you are authorized to sign this application on behalf of the applicant. 2. certify that everything stated on this application is true and correct. 3. authorize William Barnet & Son, LLC and/or Milberg Factors, Inc on behalf of William Barnet & Son, LLC to make such inquiries as are necessary to obtain credit information about the applicant and authorize applicant's bank and trade references to release information regarding the applicant's account(s). (iv) acknowledge that all sales of William Barnet & Son, LLC products to applicant, if any, would be subject to William Barnet & Son, LLC terms and conditions of sale. William Barnet & Son, LLC makes no assurance or guarantee regarding any amount of credit or the continuation of such credit to applicant. If William Barnet & Son, LLC, in its sole discretion, provides applicant with line of credit to facilitate purchases of product from William Barnet & Son, LLC such credit line may be amended, decreased, or terminated at any time at William Barnet & Son, LLC sole discretion.

Company name*
Company name 2
Address*
Street Address Street Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Please use the international country calling codes: (+___) ____ - ________
(+country code) area code - phone number
Email
Email Actions
There are no Email Adresses.
Maximum number of email adresses reached.

Email	Actions

There are no Email Adresses.

Contact Person
Contact Person Actions
There are no Entries.
Maximum number of entries reached.
Phone (general)*
Please use the international country calling codes: (+___) ____ - ________
(+country code) area code - phone number
Email (general)*
We submit all invoices electronically through email. Please note that if more than one person needs to be on this distribution then please include all appropriate parties.

Contact Person	Actions

There are no Entries.

Contact Person
Contact Person Actions
There are no Entries.
Maximum number of entries reached.
Phone (general)*
Please use the international country calling codes: (+___) ____ - ________
(+country code) area code - phone number
Email (general)*
We submit all invoices electronically through email. Please note that if more than one person needs to be on this distribution then please include all appropriate parties.

Contact Person	Actions

There are no Entries.

Additional addresses

Company name	Address	Phone	Fax	Email	Actions

There are no Entries.

Name*
First Last
Phone*
Please use the international country calling codes: (+___) ____ - ________
(+country code) area code - phone number
Email*

Bank Name*
Bank Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Details
Account Name*
Bank-Code / IBAN*
S.W.I.F.T.-Code / BIC*
ABA No.
Contact Person
First Last
Phone*
Please use the international country calling codes: (+___) ____ - ________
(+country code) area code - phone number
Contact Email*

Bank Details