New Customer Form

Please remember to submit the following form once you are complete.

If you have any questions, do not hesitate to reach out to customer service at 800.635.6779 or customerservice@datadistributing.com

If you would like to download this form instead, please click here.

Company Information


CorporationPartnershipIndividualLimited Liability Company

Accounts Payable Information

Sales Info

Tax Information

Sales tax will be added to invoices for shipments into California, Illinois, and Washington,
unless customer is either a Reseller or Tax Exempt.


YesNo

If yes, provide Resale Certificate for each applicable state.
(Seller's Permit does not meet requirement for deferring sales tax.)


YesNo

If yes provide Tax Exemption Document

Bill To Address

Ship To Address

Same as "Bill To"? If yes, go to next section.

Principle(s)

Bank Reference

Credit References

If you are using a credit card, please skip down to the next section.

Credit Card Information

~ Only needed if you intend to use your Credit Card ~

If the billing address for the Credit Card differs from the address you provided above (in section 5),
please complete below.

Credit Card Billing Address

This application is for the purpose of extension of credit following terms and conditions of the seller.
All information will be held in the strictest of confidence.

Please use your full name in the digital signature.