Vendor Application

Complete this form to register as a Maddox Vendor

Your Name *

First

Last

Title *Email *Phone Number *

Your Information

Company Name *Company Type *Tax ID Number/EIN *D&B Number *Business Address *

Line 1

Line 2

City

State

Zip Code

Country

In Business Since *Est. Annual Revenue *Number of Employees *Type of Business *Accounts Payable Contact *

First

Last

Accounts Payable Email *Accounts Payable Phone *Tax Exemption/Resale Certificate

Banking Reference

Institution Name *Bank Address *

Line 1

Line 2

City

State

Zip Code

Country

Bank Phone *

Trade References

Reference #1

Company Name *Contact Name *

First

Last

Phone Number *Email *

Reference #2

Company Name *Contact Name *

First

Last

Phone Number *Email *

Reference #2

Company Name *Contact Name *

First

Last

Phone Number *Email *

Account Information

Initial Order Amount in Dollars (If Applicable)Estimated Annual Transformer Purchases in Dollars *I Purchase Transformers *Types of Transformers I Buy *

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.

E Signature *

First

Last

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