New Customer Information Form

Legal Company Name:*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Fax Number:

Email Address:*

MAILING ADDRESS / BILL TO ADDRESS:*

Street Address Address Line 2 City State ZIP Code

SHIP TO:*

Company Name

SHIP TO ADDRESS: (All materials to be shipped here)*

Street Address Address Line 2 City State ZIP Code

OWNER NAME:*

OWNER STREET ADDRESS:*

Street Address Address Line 2 City State ZIP Code

OWNER HOME PHONE:

OWNER CELL PHONE:

SALES REPRESENTATIVES:*

AUTHORIZED TO ORDER*

SALES REPRESENTATIVES:

AUTHORIZED TO ORDER

Accts Pay Clerk:*

Website:

TAXABLE?*

YES
NO

(if NO, copy of Florida Resale Certificate must be provided)

How did you hear about United Materials?*

Do You Deal With:*

Slabs
Stone Tiles
Both

May we send Special Offers and New Arrival information?*

Yes
No

CREDIT REFERENCE & GUARANTY

Name of Applicant:*

Address:*

Street Address Address Line 2 City State ZIP Code

Phone:*

Fax:

Email Address:*

Corporation / Partnership / Sole Proprietorship:*

NAME:

Person #1

HOME ADDRESS:

Street Address Address Line 2 City State ZIP Code

HOME TELEPHONE:

NAME:

HOME ADDRESS:

Street Address Address Line 2 City State ZIP Code

HOME TELEPHONE:

NAME:

Person #3

HOME ADDRESS:

Street Address Address Line 2 City State ZIP Code

HOME TELEPHONE:

BANK REFERENCE:*

ACCOUNT NUMBER:*

TELEPHONE NUMBER:*

List Three Business References:

NAME:*

Reference #1

ADDRESS:*

Street Address Address Line 2 City State ZIP Code

TELEPHONE NUMBER:*

NAME:*

Reference #2

ADDRESS:*

Street Address Address Line 2 City State ZIP Code

TELEPHONE NUMBER:*

NAME*

Reference #3

ADDRESS:*

Street Address Address Line 2 City State ZIP Code

TELEPHONE NUMBER:*

You are authorized to contact any of all of the above references regarding our credit standing. Further, you are authorized to check with outside sources such as Dunn & Bradstreet, TRW, etc. regarding our credit standing. I (we) have read the terms and conditions and agree to abide by them.

AUTHORIZATION SIGNATURE:*

TITLE:

FULL NAME:*

DATED:*

In consideration of United Materials, Inc. extending credit to the above applicant, we the undersigned individuals, jointly and severally, as individuals, guarantee the payment of any and all future obligations of the above mentioned, which may be due and owing to United Materials, Inc., that this guarantee is continuing in nature and can only be terminated by mail and/or delivering written notice to United Materials, Inc. Individual guarantors herein further agree to pay upon demand all costs and expenses of collection including but not necessarily limited to collection fees and/or attorney fees sought for collection together with interest on the outstanding principal balance at the rate of 18% per annum or 1.5% per month on any and all invoices not paid in accordance with the terms therein.

SIGNATURE OF APPLICANT/INDIVIDUAL:*

DATED:*

SIGNATURE OF APPLICANT/INDIVIDUAL:

DATED:

DRIVER'S LICENSE #:*

Dear Valued Customer:

Presently our company is in the process of updating its customer contact information. In order to make sure everyone in your company is receiving the most up to date information, please send us an updated list of names, title, and e-mail for the authorized personnel in your office, who should receive the following: (mark an X in one or more of the boxes)

WP: Web Login
OA: Order Acknowledgement
OC: Order Cancellation
I: Invoice
P: Promotion / advertising

We would really appreciate it if you could take a few minutes to fill out the following form and either fax it to 239-593-6996 or e-mail it to [email protected]

Name

Title

Email

Name

Title

Email

Name

Title

Email

Name

Title

Email

Name

Title

Email

Name

Title

Email

Name

Title

Email

Name

Title

Email

New Customer Information Form

CREDIT REFERENCE & GUARANTY

NAPLES

JACKSONVILLE

TAMPA

ATLANTA

BOYNTON BEACH

ORLANDO NOW OPEN

DISCLAIMER