We wish to open an account with your company and desire credit to be extended to us in accordance with your terms, which are "NET 30 Days". In accordance with these terms, we understand that all charges are due for payment 30 days after date invoice. We hereby authorize Böttcher America Corporation to verify the facts listed below.

Registered Trade Name
Mailing Address
City, State, Zip
Shipping Address
City, State, Zip
Shipping County
Phone
Fax
New Customer		YesNo
Type of Business
Years in Business
Tax Exempt		YesNo (If you answered YES, please fax a copy of certificate to Bottcher at 410-273-7174.)
		Sole Proprietorship
		Partnership
		Corporation
State of Incorporation
Date Established
Officers or Partners

Bank Reference
Name
Account#
Address
City, State, Zip
Officer to Contact
Phone
Trade Reference
1. Name
Account#
Address
City, State, Zip
Phone
2. Name
Account#
Address
City, State, Zip
Phone
3. Name
Account#
Address
City, State, Zip
Phone
Completed By
Title
Email