New Account Form

New Account Form
Legal/Trade Name :
Billing Address
Billing Address	Street Number and Name :
	City :
	State/Province :
	Zip/Postal Code :
	Contact Name :
	Phone # :
	Fax # :
	Email :
Shipping Address (if different than Billing)
Shipping Address (if different than Billing)	Street Number and Name :
	City :
	State/Province :
	Zip/Postal Code :
	Contact Name :
	Phone # :
	Fax # :
	Email :
Accounting and Payment Information

A/P Contact		Market Segment: (please choose) HEDBusinessK-12Workforce Development
Phone #
Fax :
E-mail:		Requested Terms: (please choose) Credit CardNet-30 Trade References may be requested
Federal ID
Tax Exempt #

AGREEMENT FOR CREDIT SALES: The above information is for the purpose of obtaining credit and is warranted to be true. I hereby agree to pay all invoices within 30 days of receipt of invoice or as expressly agreed. Interest of 2% may be charged on overdue invoices. I hereby authorize CCI Learning Solutions Inc. to obtain such credit reports or other information as may be deemed necessary in connection with the establishment and maintenance of a credit account.I agree to agreement written above
Authorized Applicant:	Title:	Date:

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