New Account Form – CCI Learning

New Account Form
Billing Address
Billing Address
	Legal/Trade Name :
	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)	Legal/Trade Name :
	Street Number and Name :
	City :
	State/Province :
	Zip/Postal Code :
	Contact Name :
	Phone # :
	Fax # :
	Email :
Accounting and Payment Information	Contact Name :
	Phone Number :
	Email :
	Note: Trade References may be required.

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: