Customer Application - PM Contracting

Service Site:

Company Name

Physical Address

Billing:

Company Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Fax

IRS EIN

Check One

Corporation
Partnership
Sole Owner
Other

How long in business?

How long at present location?

How many employees?

Is the business:

Owned
Leased

Accounts Payable Contact:

Name

First

Last

Phone

Email

Site Contact:

Name

First

Last

Phone

Email

Principal/Owner Information

Name

First

Last

Title

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Banking Reference

Name of Bank

Branch

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Credit References (3):

1.) Company Name

Contact Name

Address

Phone

Fax

2.) Company Name

Contact Name

Address

Phone

Fax

3.) Company Name

Contact Name

Address

Phone

Fax

Release of Information Authorization

Print Name

Title

By checking this box, I hereby certify that the information contained herein is complete and accurate. I authorize the release of credit information and any other inquiry deemed necessary by PM Contracting, Inc. or its affiliates for the purpose of business evaluation.

Yes, I authorize the release of information.

Date

Please upload a current W-9 and certificate of insurance with PM Contracting, Inc. listed as the Certificate Holder.

Click or drag files to this area to upload. You can upload up to 2 files.