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| CUSTOMER I.D. ________ NAME:_________________________________________________________ ADDRESS:_____________________________________________________ CITY:_______________________________STATE:_______ZIP:___________ CONTACT:___________________________POSITION:__________________ TELEPHONE:________________________FAX:________________________ TAXABLE: YES___ NO___ TAX EXEMPT #____________________________ SPECIAL INSTRUCTIONS:_________________________________________ ______________________________________________________________ AUTHORIZED SIGNATURE:________________________________________ TERMS - NET 30 CREDIT REFERENCE #1:_________________________________________ _____________________________________________________________ CREDIT REFERENCE #2:_________________________________________ _____________________________________________________________ |
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