North American Camera, LLC

General Information
Name of Firm or Individual*
Phone Number*
Email*
Fax*
Address*
City*
State*
Zip*
Ownership
Date Business Started*
Business Type*

Individual Sole Proprietor LLC Partnership Corporation
Name of Principal 1*
Title*
Social Security*
Home Address*
Phone Number*
Name of Principal 2
Title
Social Security
Home Address
Phone Number
Business Information
What is the nature of your company's business?*
Resale Certificate ID#
Not for Profit ID#
Billing and Shipping Addresses

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Billing Address
City
State
Zip
Shipping Address
City
State
Zip
Finance
Bank*
Contact Name*
Phone*
Fax*
City*
Account Number*
Trade Credit References
Business 1*
Account Number*
Contact Name*
Phone*
Fax
Business 2*
Account Number*
Contact Name*
Phone*
Fax
Business 3*
Account Number*
Contact Name*
Phone*
Fax
Shipping Information
FedEx Account #
UPS Account #
Credit Card Information
Name on Card*
Credit Card Number*
Expiration Date*
Billing Address of Card*
Billing City*
Billing State*
Billing Zip*
3 Digit Security Code*
We certify that the information above is correct and authorize the above named banks and/or trade references to disclose any information on credit worthiness. We fully understand your credit terms and agree to the proper payment in consideration of extended credit.
Signed*
Title*
Date*

General Information