New Account Form

New Account Form

Legal/Trade Name :
Billing Address
Billing Address
Shipping Address (if different than Billing)
Shipping Address
(if different than Billing)

Accounting and Payment Information

A/P Contact
Market Segment: (please choose)

Phone #
Fax :
E-mail:
Requested Terms: (please choose)


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: